OFFICIAL RECORDS OF THE WORLD HEALTH ORGANIZATION No. 94
FIRST REPORT ON THE WORLD HEALTH SITUATION
1954 -1956
WORLD HEALTH ORGANIZATION PALAIS DES NATIONS GENEVA
May 1959 NOTE
The Ninth World Health Assembly in May 1956 invited Members of WHO to prepare, as a step towards the fulfilment of their obligations under Article 61 of the Constitution, a report covering as far as possible the period 1954 to the end of 1956.1At the same time the Assembly requested the Director -General to prepare for the Eleventh World Health Assembly the first report on the world health situation, summarizing those reports. In June 1958 the Eleventh World Health Assembly discussed the report prepared by the Director- General, thanked the Member governments for their assistance in providing material and invited them to submit amendments for the final report.2 The " general survey" presented as Part I of this volume contains a synthesis, under broad subject headings, of the reports received from Member States.The reports themselves, with the amendments submitted by the governments, are reproduced in Part II.
1 Resolution WHA9.27: Off: Rec. Wld Hith Org. 71, 27 2 Resolution WHA11.38: Off: Rec. Wld Hlth Org. 87, 34
PRINTED IN SWITZERLAND CONTENTS
Page Preface vII
Introduction 1
PART I - GENERAL SURVEY
Chapter 1.Influences affecting the health of the peoples 7
1.Climate and other geographical conditions 7 2.Environmental conditions 8 3.General influences 10
Chapter 2.The state of the public health 14 1.The measurement of health 14 2.Sources of statistical information 15 3.Trends in the state of health of various countries in the course of development 18 4. Development in physical and mental health.Nutritional standards 23
Chapter 3.Administration of health services and activities 26 1. The role of various government departments 26 2. The role and structure of health administrations 29
Chapter 4.The distribution of functions in the health services 33 1.Medical care, including hospital, clinic, rehabilitation and home services 33 2.Maternal and child health 35 3.Mental health 38 4.Occupational health 42 5.Health education 45 6.Dental care 47 7.Nutrition 49 8.Veterinary public health 51 9.Health and the environment 52 10. The control of communicable disease 57 11.Chronic and degenerative disorders and aging 61
Chapter 5.Institutions and field establishments 65 1.National health institutes, including public health laboratories 65 2.Hospitals, out -patient departments, health centres, rural health units, etc. 67 3.Statistical services 72 4.Domiciliary health services 74 5.Institutions for the production and control of drugs, biological preparations, and foodstuffs 76 Page
Chapter 6.Education and training 81
1.Medical education 81 2.Nursing education, including training in public health nursing 85 3.Auxiliary personnel in the health services 87
Chapter 7.Future developments 89 1.Trends in health promotion 89 2. Developments in administration 90 3.Long -range planning 91 4.Short -term independent programmes 91 5. Communicable disease control 92 6.Rural health development 92 7.Supply of medical manpower 92 8.Improvement of living and working environment 93 9.Plans for community development 93 10.Health aspects of radiation 93 11.Field research and investigation 94 12.International collaboration 95
PART II- COUNTRY REVIEWS
Page Page African Region African Region (continued)
Angola 101 Seychelles 138 Basutoland 102 Sierra Leone 139 Bechuanaland Protectorate 104 Swaziland 141 Belgian Congo 105 Tanganyika 142 British Somaliland Protectorate 107 Autonomous Republic of Togo 144 Cape Verde 109 Uganda 145 Comoro Archipelago 110 Union of South Africa. 148 French Equatorial Africa 111 Zanzibar 150 French West Africa 113 Gambia (Colony and Protectorate) 115 Ghana 118 Region of the Americas Kenya (Colony and Protectorate) 120 Alaska 155 Liberia 122 American Virgin Islands 156 Madagascar 124 Argentina 157 Mauritius and Dependencies 126 Bahama Islands 159 Mozambique 127 Barbados 159 Federation of Nigeria 128 Bermuda 161 Portuguese Guinea 131 Bolivia 162 Réunion 132 Brazil 164 Federation of Rhodesia and Nyasaland 133 British Guiana 166 Ruanda -Urundi 135 British Honduras 167 St Helena and Dependencies 136 Canada 168 Sao Tomé and Principe 137 Chile 173 - Iv - Page Page Region of the Americas (continued) European Region (continued) Colombia 174 Federal Republic of Germany 255 Costa Rica 176 Gibraltar 258 Cuba 177 Greece 259 Dominican Republic 178 Hungary 261 Ecuador 180 Iceland 265 El Salvador 181 Ireland 267 French Departments in America 182 Italy 271 Guatemala 183 Luxembourg 275 Haiti 184 Monaco 276 Hawaii 186 Morocco 277 Honduras 187 Netherlands 278 Jamaica 187 Norway 282 Leeward Islands 189 Poland 285 Mexico 191 Portugal 288 Netherlands Antilles 193 Romania 290 Nicaragua 194 Spain 294 Panama 195 Sweden 296 Panama Canal Zone 196 Switzerland 298 Paraguay 197 Turkey 300 Peru 198 Union of Soviet Socialist Republics 304 Puerto Rico 200 United Kingdom of Great Britain and Northern Ire - Surinam 201 land 307 Trinidad and Tobago 202 Yugoslavia 313 United States of America 203 Uruguay 206 Eastern Mediterranean Region Venezuela 207 Aden (Colony and Protectorate) Windward Islands 209 319 Cyprus 320 Egypt 323 South -East Asia Region Ethiopia 326 Afghanistan 215 French Somaliland 327 Burma 216 Iran 328 Ceylon 218 Iraq 329 India 220 Israel 331 Indonesia 222 Hashemite Kingdom of Jordan 333 Nepal 225 Lebanon 334 Portuguese India 226 United Kingdom of Libya 335 Thailand 227 Pakistan 337 Saudi Arabia 339 European Region Sudan 340 Syria 342 Austria 233 Tunisia 343 Belgium 235 Yemen 344 Bulgaria 238 Czechoslovakia 240 Denmark 242 Western Pacific Region Finland 247 American Samoa 347 France 251 Australia 347 - V - Page Page Western Pacific Region (continued) Western Pacific Region (continued) British Solomon Islands Protectorate 350 New Caledonia and Dependencies 371 Brunei 351 New Hebrides 372 Cambodia 352 New Zealand 373 Republic of China 353 Niue Island 374 Cook Islands 355 North Borneo 375 Fiji 356 Pacific Islands 376 French Polynesia 357 Papua and New Guinea 377 Gilbert and Ellice Islands 358 Republic of the Philippines 378 Guam 359 Portuguese Timor 381 Hong Kong 360 Sarawak 381 Japan 362 Singapore 382 Republic of Korea 364 Tokelau Islands 384 Laos 366 Tonga 385 Macao 367 Viet Nam 386 Federation of Malaya 368 Western Samoa 387 Netherlands New Guinea 370
Index of countries 391
FIGURES
Fig. 1. Climatic regions facing 8 Fig.2.Density of the population facing 9 Fig.3.Notification of smallpox cases, by continents, 1948 -57 58 Fig.4. Reduction of cholera prevalence, 1948 -57 60 Fig.5. Regression of typhus: cases of louse -borne typhus reported from 1945 to 1957 60 Fig.6.African Region 100 Fig.7. Region of the Americas 154 Fig.8.South -East Asia Region 214 Fig.9.European Region 232 Fig, 10.Eastern Mediterranean Region 318 Fig. 11.Western Pacific Region 346
- VI - PREFACE
THE present review, covering the period 1954 -56, is the first report on the world health situation. The Annual Reports of the Director -General have dealt with the work of WHO year by year, and a comprehensive account of the Organization's achievements in various countries has been presented in this way.This Annual Report has deservedly become an essential feature of the functions of WHO, and the accumulated experience derived from ten years' activity has made a genuine contribution to international history.Nevertheless, for various reasons, the obligation accepted by Member States in Article 61 of the Constitution of WHO to report on the progress achieved towards the improvement of health has remained in abeyance during these early years.This fact has been recognized by the World Health Assembly and led it recently to reaffirm'. the responsibility of the World Health Organization to review the health situation in the world and to confirm that this is another essential function of the Organization. The services that WHO was privileged to give to many nations in such matters as education and training of personnel, the control of communicable diseases, and public health administration have been documented in a number of publications, including the Bulletin of the World Health Organization and the Technical Report Series ; but deeper analysis shows how important it is also for each country to have an opportunity of telling its own story about its health situation.As countries differ so much in size, population, and resources, it is essential that each account of the progress of the health services should be illuminated against a background of reality.It would be absurd to expect a small, sparsely populated country to have the same design for health as a highly industrialized state of enormous dimensions; yet its story of overcoming difficulties might be well understood by and become a source of great encouragement to other countries on the same path of progress. For an international organization like WHO one of the methods of serving Member States is to present faithfully in clear, simple outline a picture of the state of health of each country and territory, based on the information at present available, and to focus a spotlight with the correct degree of intensity on new developments.By this means each country would keep the world informed of its proposals and undertakings, and so all the peoples would become more familiar with one another's problems in an intelligible relation to resources of personnel, money, and equipment.Furthermore, the world would discover what is being done in the great endeavour to improve health on a global scale. I would ask the national health authorities, therefore, in reading this report, to direct their attention especially to the efforts which are being made, often against mighty odds, to promote the health and welfare of peoples who were previously little known to them.That is the reason why the description of the health services of each country is preceded by a brief, very simple, background of reference and allusion which can readily be followed by all.National health authorities have, of course, a detailed knowledge of their own situation and services, and they may well feel -in the larger countries especially - that some of the information is too obvious for serious presentation. Yet, when one reads a review of an unfamiliar country, a minimum background of general information is greatly appreciated, as giving the health situation in a realistic setting and showing its stage of development. Even in its infancy this report serves two distinct purposes.One of these is to provide a descrip- tion (so far as information is available) of the health situation in each political or administrative unit
Resolution WHA11.38 of the Eleventh World Health Assembly, June 1958(Off.Rec.WId HlthOrg. 87, ,34) of population, whether independent or non -self -governing, so that a really world -wide consideration of the health of the people is possible.It is probably the first time in international service that the countries of the world have supplied the material for such an extensive coverage in a single field.The general information presented is not as universal as it should be, and, needless to say, is far from adequate, but it does at least provide the background necessary for an understanding of world health.Only gradually, and with the active co- operation of all Member States, will it be possible to build up a complete picture.This cannot be done in a year possibly not in a decade ; but each advance in the exchange of experience is ground gained.Effective and continuous international co- operation may be confidently expected, when the national health administrations realize how similar are their problems in essentials to those facing other countries, and understand the ineluctable stages of progress from one era to another. The second purpose of this report is to cast a strong light on various aspects of public health work, as it is observed in different countries, from the standpoint of modern medicine, not as an isolated discipline, but as a living branch of the social and biological sciences. The first seven chapters, which have been prepared as an introduction to the 157 brief country reviews, serve, not as a summary, but as a synthesis of the subjects dealt with in the reviews and presented by the individual countries.The varying ideals and practices of health do not represent what is happen- ing in any one country, but they do give a composite picture of a series of outstanding events and efforts in many lands.The main part of the report thus offers a comprehensive review of the present " health situation" of the world in a collective sense. What of the future ?In dealing with a branch of the social and biological sciences directly connected with human welfare, a report on the health situation would not be complete unless all social, cultural, and economic aspects affecting the health of a population were taken into consideration.From the point of view of WHO this is particularly important because of the definition of health written into its Constitution.Present knowledge and experience in the fields of medicine and public health have enabled workers to plan their activities so as to erect reasonable safeguards for the mental and physical health of a people, but the lack of comparable information on " social well -being " confronts them with many problems that are beyond their control.Health administrators are considering these pressing questions and becoming familiar with the social and economic hazards affecting the health of the people, and in this way are moving towards the goals of social well -being. This first report on the world health situation is in some respects incomplete, but to make a begin- ning is an act of faith.This is the rough framework of a structure which I believe will become in the passage of the years stable, well -knit and fully representative of reality.
Director- General INTRODUCTION
In his Introduction to the Annual Report for the might well defeat its own ends by making people year 1954 the Director -General observed that the most unnecessarilysickness -conscious.Inaddition,the encouraging aspect of the requests received by the ideal would be so remote from reality in some coun- World Health Organization during the year was the tries as to be a positive hindrance to progress.We active desire shown by many countries to obtain must be content with a more simple approach: to WHO's help in working out long -term plans for the secure the highest practicable level of medical care progressive and orderly development of their public and build on that.The best beginning is to look health services.This trend, as many countries have closely at what there is -what istechnically and shown in their returns, is of the utmost importance educationally possible in a given country or region -, because it represents a movement towards an organized bearing in mind the limitations imposed by customs, system of planning and achievement.The advance traditions, and resources, and in the light of these goesfurther thanthat,astheDirector -General considerations to review the situation during the pointed out: it indicates an increasing readiness to period covered by the report.That is the kind of undertake joint action in solving problems that affect foundation on which we can build.It is true that more than one country-as is well demonstrated in acarefullyworded and comprehensivedescrip- the considerable number of inter -country and inter- tion of the state of ideal health has been written regional schemes. into the Constitution of the World Health Organiza- In the Report for the following year it was pointed tion.It is right and proper that such ideals should out that the beneficial effects of the campaigns for be set out; but it is essential that the contemplation advancement would constitute concrete gains for of these goals should not detract from action to meet public health only if we can succeed in effectively the immediate urgencies of health care and health strengthening national health services.From these promotion.First consideration should therefore be and other indications we can see that nations, large given to the range of achievement compatible with and small, are aware of the value of self -help in steady progress in a community, and the aim should taking responsibility for the development of their be to show what can be done here and now to promote own services; and that they seek services mainly in health in the broadest and most practicable sense of three directions: the world struggle against communic- the word. able diseases, the strengthening of the health services How can this be done ?The first step is to invite which have already been established, and the raising peoples to speak for themselves and tell their own of standards of education and training for all types story of both difficulties and achievements.This of health worker.Hitherto, and quite rightly, the has recently been carried out, and many governments World Health Organization has stated year by year have answered questions, simply and with a deep the aims of a health programme and the steps it has sense of public duty, about the health and welfare of taken, at the request of one country and another, to their people.Others, who have not yet been in a move towards these aims.Nevertheless, one can position to compile full and accurate statistical data, discern an uneasy feeling that in some instances the have supplied valuable information obtained from very inaccessibility of the mountain peaks of health sample surveys which gives a very good indication and welfare has served to discourage a country, when of general trends in such matters as population and a more modest goal might have offered encourage- indices of health.Some countries have not yet ment.Before reaching the heights it is essential to produced basic figures, but it is hoped that future explore the land that lies between. developments will be in that direction, as these data This idea may be simply illustrated by reference to are of such great importance to the world community. theeducation and training of health personnel. There are several ways in which the story of a Ideally it may be desirable to have in all areas a full people can be told, and each of them has its own par- quota of highly trained medical and nursing staff, ticular advantages and drawbacks.The first method, with the whole range of auxiliaries that a fully de- as has been indicated, is to maintain careful records veloped service demands.Yet this very plenitude of events as they happen -events such as birth, death - 1 - 2 FIRST REPORT ON THE WORLD HEALTH SITUATION and sickness and the appropriate rates, infant and needs of the country as a whole.For this reason maternal mortality, causes of disease and death at alone there is a great deal to be said for the general various ages, nutritional and educational states, and survey of a limited area, especially when the workers so on.In the second place, the history of a people and the ordinary people on the spot feel themselves may be written currently by experts- advisers selected to be partners in the enterprise. on account of their specialized knowledge of particular What is the value for a country of an annual report subjects -, and by others who have an inquiring mind written by the national director of health ?The and a ready pen.And thirdly, at a level which is answer is threefold.In the first place it makes a even more important, the history of a people can be unique contribution to health progress by encouraging written continuously by the people themselves.In local officers to report on the situation in their areas, every area of the world there should be a growing as they see it, accurately and in simple terms.In volume of written experience covering the progress this way they feel that they are making a really personal of each nation and state, year by year, setting out in contribution to the records of their country and are simple terms the existing situation and the ways in taking part in the building of a service.The second which the next stages can be planned and reached. point is that the national director himself is engaged In many ways the story as told by the nations them- in an important and interesting work of correlation, selves is the most vital one; it may be faulty in detail, bringing together local information on health, written biased in one way or another, or even distorted by perhaps in different languages and covering districts conflicting opinion, but itis nevertheless what the with widely varying customs and traditions.It is people thought and said at a particular time. good that he should feel responsible to his own people Preventive medicine without records is like a ship and government for reporting on the health situation. without a compass.Vital statistics have contributed His reports will be of value to his whole department immensely to the advancement of knowledge, because as the years go on, as they will enable exact compari- they have given direction to its progress.As our sons to be made of the service as a whole, as well as knowledge of the causes of things increases, the need of its more -detailed components, such as maternal for more extensive records increases also.Never- and child healthor communicablediseases.In theless, we must constantly evaluate our statistics to addition, it is generally found that annual reports on find out whether they are in fact leading us forward the health of a community are of great interest and or merely providingroutinefiguresforgeneral value to neighbouring medical officers, partly for com- administrative purposes.In the assessment of the parative purposes and partly because they sometimes health and well-being of nations we can no longer serve to clear up problems that refuse to be contained be content with the normal statistical material, useful by man -made boundaries.In producing his annual as it is in giving outlines for comparison. A broaden- report the director of health is giving an account of ing of statistical information isessential in areas his stewardship.In regard to the expenditure of time where the ordinary returns are poor in quality and in and money, he is offering comparison with other quantity.In cases like these it is of course possible activities and expenditures and is encouraging sound and often desirable to institute a series of special rivalry and team -work with other departments of surveys -such as, for example, of housing, communic- government.In our times the national director of able disease, chronic sickness, mental ill- health and the health cannot do his duties in an isolated compart- problems of the aged.These surveys, carried out ment: health, medical care, education, and environ- by specialists, have very great value; but they are mental progress are inseparable community func- open to certain objections, notably in areas where tions. the co- operation of the people is at any time difficult. There is a third justification for the issue of an There is always a considerable risk of overlapping annual report by the national director of health.The when each survey requires, as it commonly does, world has become a small place, and all countries are visits to individual homes or to the same groups of neighbours.His nation now lives in a parish of the field workers.The same background has to be world community.His report therefore circulates explored, the same questions have to be asked over among peoples who have joint interests, many pro- and over again, by different groups of specialists; and blems in common, and activities which can be success- the inevitable end -result is the exasperation of the ful only as co- operativeefforts.In the country people exposed to this procedure.In addition, there reviews, contained in Part II of this work, the principal is the risk that a series of specialized inquiries, sound aim has been to set out in simple terms two descriptive as they may well be in themselves, will lead by their accounts of each country and its people.The first very specialism to a somewhat biased view of the part, which is the background information, consists INTRODUCTION 3 of a short summary of generally ascertainable facts. prepared by each country.These descriptions have The reason for giving thisstraightforward general been obtained from recent books of reference, pub- information is that it sets the stage, as it were, for lished reports, and other official and generally acces- the important second part.There have been so many sible records.There are probably still errors of fact changes in recent years in government and boundaries and interpretation, as well as gaps in the information and in material developments that it seems desirable to presented, and efforts will be made to ensure that sketch a simple, factual background for the review future editions of the report are more complete.
Part I
GENERAL SURVEY
CHAPTER 1
INFLUENCES AFFECTING THE HEALTH OF THE PEOPLES
1.CLIMATE today.It helps to place present health developments AND OTHER GEOGRAPHICAL CONDITIONS in their proper perspective and, in fairness to those countriesin which the present showing appears In order to draw a picture of the world health unsatisfactory, draws attention to the natural handi- situation one has to collect and sift a great deal of caps under which they have been labouring.The evidence, statistical and otherwise, about the state of process may help us to forecast what further progress health of the peoples, the prevalence of disease, and may be made as well as to appreciate the significance the records of death in every country and territory. and merit of the advances that have already been If this mass of evidence is plotted on a map, the effect achieved. is that of a painting of the pointilliste school, in which every dab of the brush, while having no individual The health effects of isolation and agglomeration significance, contributes to the general effect.In this case, the general effect is quite clear.The darker Apart from the general consequences of man's shades, if they represent the higher levels of mortality, isolation or agglomeration on his social and cultural generally show in the tropical and equatorial coun- development, there were certain immediate and direct tries.Indeed the darkening of the map is apparent results.Complete isolation in the narrow field of in the comparison not only of countries but also of public health resulted, after one or two generations parts of countries; even the latter may be large without outside contacts, in the loss of acquired enough to cover several climates.Examples are immunity to many of the commoner infections.An the United States of America, Chile, China and even isolated people may be healthy and their physique Italy. sound if the food supply is adequate, but they become A closer examination of the map reveals further increasinglysusceptibletocertaininfections.If that those countries which are contiguous and generally traders or seamen from without come into contact share the same climatic conditions have very similar with them, carrying the germs of even the milder levels of health.This is true also of countries which, diseases, an epidemic breaks out in the community although far distant in different hemispheres, enjoy and often proves very serious and widespread.This similar climates. accounts for the heavy destruction of isolated settle- If we compare a health map with one which deline- ments, as, for example, in the islands of the Pacific, ates education we can see that health and education, as a result of the introduction of measles, or, more expressed in terms of literacy and high learning, are recently, the widespread crippling from poliomyelitis closely correlated.If we could draw a map expressing among similar populations. economic development, not in the form of national Agglomeration, on the other hand, whether in agriculture, mining or oil production, but in terms nomadic tribes or villages, creates more opportunities of the buying power of average individual incomes, for immunizing doses of the commoner diseases; we could see once more an association between health frequency of infection and therefore of immunity and economic development, and the pattern would increases with the size of the population concerned. be clear enough to eliminate the effect of chance. In the large urban communities the chances are Health, education and economics do not, of course, greatest for acquiring infection and building up influence climate but, as we shall see, they have been resistance at an early age.So long as the population themselves largely influenced by it and by other geo- of villages had little contact with the large towns, the graphic factors. people remained relatively healthy, but they fell an Even a general, if rather sketchy, analysis of the easy prey to communicable diseases, notably tubercu- past influence of geography on health has its place in losis, when their contacts with the towns became a document on the health situation as we observe it frequent.That is why the " sturdy " country recruit - 7 - 8 FIRST REPORT ON THE WORLD HEALTH SITUATION often spent a substantial part of his first year of For all practical purposes the living environment of military service under medical care, while the phy- man has been controlled and improved beyond sically inferior town -bred recruit went unscathed. measure by the development of mechanical devices. That is the reason also why in urbanized countries The range of the habitable world is being extended communicable diseases were first regarded as the year by year by developments in central heating and scourge of large cities, but in the course of time they air conditioning and protection by modern insulation invaded centrifugally the more remote towns and against excessive heat and cold.New methods of villages, eventually to dwindle. land irrigationdevised by man's ingenuity and As regards tuberculosis, for example, this process perseverance have greatly enlarged the scope and was observed in most European countries during range of food production.Water has been harnessed the last century and is still going on in many parts of for the production of electricity, and for land irrigation Africa, South America, and Asia. in zones which would otherwise be arid.The sea Infection of the population and resulting immunity itself has been swept out to provide more fertile land; are not, of course, the only effect of human agglomer- it has been explored for all its treasures of food and ation.Whether in village or town, the congregation is now being brought into subjection for the production of human beings leads to the pollution of the water of unlimited heat and power. supply and of the soil, causing water -borne and food- borne diseases to which fly -breeding adds its quota. Human congregation in villages has also increased 2. ENVIRONMENTAL CONDITIONS theestablishmentand maintenanceofparasitic diseases of all types -particularly malaria--by pro- The influence of environmental conditions on the viding a permanent human reservoir.One of the health of an area has a direct and an indirect, or great developments of the past century has been the secondary, effect.The provision of uncontaminated control by conscious sanitary effort of these natural water to a city results directly in a fall in the water- breeding -grounds of disease. borne diseases such as typhoid fever and other enteric Urban development has created its own health infections.The secondary effect is dependent upon problems- chronic and acuterespiratorydiseases the use made of health services by the citizens. resulting from air pollution; occupational diseases, The relation of better health to improved environ- including pneumoconiosis; and psychosomatic condi- ment has been so well established that it scarcely tionsand cardiovasculardiseasesresulting from needs further substantiation. A study of the falling various stresses of modern life.These ills are too death and sickness rates during the past century much in the minds of present -day health officers to illustrates either that there is a direct relationship to need more than a passing mention. the awakening which took place during this period in sanitary science, or that both trends have been the Breaking the chain between climate and health result of some common factor, such as marked social betterment.The evidencestronglysuggeststhat In a general way the present -day distribution of there are many direct relationships: for example, in mankind over the earth's surface, favoured in the the city of Philadelphia before 1906 the rates for temperate zones and to some extent hampered in the typhoid fever reached heights of between 600 and tropical zones as regards both health and social and 700 cases of sickness per 100 000 population.In 1906 economic development, doesconfirmthestrong filtration was installed in the city water supply and association between health and geographical factors. four years later the typhoid case rate had dropped to On the other hand, we must recognize that modern less than 100 per 100 000 population.The practice techniques are modifying these factors to an increasing of chlorination was begun in 1913 and since that extent.Thanks to the increase in scientific know- time the annual sickness rate has been invariably ledge and its application, the chain of influence between below 50.Today, it has virtually reached vanishing climate and health can now be broken at almost any point. point.Modern transport makes it possible to feed In the United Kingdom of Great Britain and Nor- men in barren areas and tofurnish them with thern Ireland a similar direct relationship can be dwellingscomfortableineither glacial or torrid observed.Not only have the large cities of the zones.New methods of medical care are protect- United Kingdom been supplied during the century ing human beingsto an increasing degree against with comprehensive water and sewage -disposal sys- the various organisms to which they have been a tems, but at the present time there are few communities natural prey. of more than 2500 people that do not have a public FIG. 2.DENSITY OF THE POPULATION
\.\ ;\ : \',,'.
\ :\\\\\\\ \ \\\\\:\\\\\, \\\\\\\\\\\\\ \\\yw \\\\\\\\\ `\\\\\ ¡\\\\\\\\\\ \\\\\\\\\ \\\\\\\\\\\\\\\\\\\\\\\\\\\\ \\\ . \ \\\\\\\\\\\\\\\\\A\\\ \\\NS \v--à \ \\\\\\\\\\\\\\\\\\\\\ \\\\\\\\\\\ \\\'. \\\\\\\\\\\\\ \ \\\\\\\<\\,)\\ \ \\\\\\\\\\\\\\\\\\\\\\ \\ \\\\\\\\\\\\\\\\\\ \ \\\\\\\\\\\\ \\\\\\\\\\\\\\\\\\\\\\\\\\\\\\\\\\\\\\\\\\\\\\\\ \\ \\\\\\7\\\\\\\\\\\\\\\\\\\\\\ '"\\\\"\\\ \\\\\\\\\\\\\\\\\\\\\\\\\\\\\\\\\\\\\\\\\\\\\\\\\\ \\\\\.\\\\\\\\\\\\\\\\\\\ \\\\\\\\\\\\\\\\\\\\\\\\\\\\\\\\\\\\\\\\\\\\\\ \\\\S\\\\\\\\\\\\\\\\\\\S\S\\\\S\S \\\\\\\\\\\\\\\\\\\\\\\\\\\\\\\\\\\\\\\\\\\\\\ \\\\\\\\\\\\\\, \\\\\\\ ,; \\\\\\\\\\\\\\\\\\\\\\\\\\\\\\\\\\\\\\\\\\\\\\\\\\\\\\\\\\\\\\\\\\\\\\\\\\\\\\\\\\\\\\\\\\\\\\\\\\\ iÿ y::t., \.:.;;;:.::;; \\\\\\\\\\\\\\\\\\\\\\\\\\\\\\\\\\\\\\\ \\\\\\.\\\\\\\\\..\\\\\\\\\\\\\\\\\\\\\\\\\\ \\\\\\\\\\\\\\\\\ ...... \\\\\\\\\\\\\\\\\\\\\\\\\\\ .\\\\\\\\\\\\\\\\\\\.\\\\\\ .\\\\\\\\\\\\\\\\\\\\.\.\.N
,\..\\\.\\\.\>..w,\\ . \.\.::...... ::;:::.::: ? ::>::::>>: .::>:::: <':
. \\\\\\\ \\\\ \\\\\\\\\\\ \ \\\\\\\\\\\\\\\\\\\\\\\\\\\\` \\\\ \\.\\\\ \\\\\\\\\\ \\\ \\:<. \\\ \.\
vvvvvvvv _`\\\>;::: ° \\\\\\\\\ \\\\\\\\\\\\\\:::» `\`\"`"\\\\"\'''''''\"V\v\\\\\\\\\\\\\\\\\\\.\\\\\\\:;ï> \\\\\\\\\\\\\\\\\\\\\\\\\\\\\\\\\\\\\\\\\\\\\\\\\ .'.,..i`BiiA`\\\\\\\i's>_'`::\:: \\`\\\
DENSITY OP THE POPULATION
Per square kilometre Per square mile
0 . 0.4 D- 1 FIG. 1.CLIMATIC REGIONS
_
4 .. t
1 1 1
lbw . 1 ..
i , 1 . NA 1 iiii .91,11111,Illillii ,- -,, 11 .1* ' y 6- - /2 - , ' 1 1 , ar,iii yi ' / ' 1 -, 1 .))::"..0, 0441 4.3*.././."//,//, / - , 1 .27 , s Aki...4), :",', A%sotto 1 **. -- , _-_ _ _ _ b 4).4 /// - ..,--,2" 8.-.. . . .-(46.:!.. . . -...... v,. ., / ------. ,, ,/1.-- ',/./ ------. .?, - ... ., .. (.(- to 4 I It It. "IA ...... ilk :'," .',21#-f" ., , '''' ik, ...... -;:" .. ,.,..",. ";,'"i . ' /-_-_-iii====.7_-____- ',.. '2',Z,(< ../ 1./ ' s. 4, r.,,, i ) .:»::::':* /------o,- . ...:::,.... ------/ "./ ' ,,,, ___- - --_ ____- --- __- - - ,'- 44" _-_------s . ..t.v / , ' . . .. to - r ;,r* r. ofro:y,'..*::...... L...,.., .... ' 44*.v.0 , ' . ., ...... ,.,., , . , .7 ,, ...... w.. 7,74, , , ... .// . , ...:::::,. ...' - ..-.0....:.... ,".:.-/77,/ .. .4. MI6 ... :0 ..7,...k// ./.<%//z/7 . --iv. . A*. . ::-.: .....:...:.: -. : :-. .s...... : ..,,:-. # :.::.:..... g 7., /
.:,.....x.: - Ig. .-, . . , ...., 7 .. ...57/ ...... , ...... : - .. i 1 % "...A- ... . , 7 1 _./--/ . , 6 .. * -- :.. -:: ... ' / ,(. / ' ' ; . . /// , ...... ,/,/:v. , %. , ...:,._ jp. , .. 4,..: ..,/,
7' ././...... / to./ ... . e sr,, go ou ,,"' ri 110,s4, . ,,,. r 7/ , . % , .' // 46111111% , ., /. ','':....,. sAr.C. aogo.'s' ''''.- ,',. /./". or , - - . *o ...- .. /// 4 ...
.44.14, , ;.`4 %V.-4., A I.; // / o Y /4.:.41:.:.,I. ).,.**Z.&:::t.))))))_..,. s.... ,,,,. / / 0
. . / . . . 0...... '44 v) :::: - ".1:iii:::::::::::g. - .0.' .4 , ' ' . - V. _ ' CLIMATES: -. \\, ' » . .. Tropical Rainforest , .04. MI \ ,:,,`,S °P.._ -..,.+.4 ero-_ ::::!:7- TROPICAL MTropical Savanna OW mytt s t e p p e 1 0 ARID Desert II; I
Mild - summer rain # ,
Mild - winter rain 1111P'.r I MESOTHERMAL ,--- I f' t ' r_=_:-._ Moderate continental 1 i % .7t1 1 1 l I Ii I Moderate marine 1,1
Other - with severe winters MICROTHERMAL
WHO 8202
Kiippen's classification adapted from R. E. James, R. J. Russell & G. T. Renner INFLUENCES AFFECTING THE HEALTH OF THE PEOPLES 9 water supply and, in most cases, a sewerage system warmer zones where the public supply is unsafe. as well.A constantly increasing number of smaller Frequently its quantity is also poor and too limited towns and villages are now served also by regional to reach the suburban slums just where it is most systems of water supply and drainage.These sanitary needed.The result is that many of the inhabitants improvements have had a direct effect on the typhoid of these rapidly growing, unplanned, crowded districts death rate.During the period 1901 -05 the average have to go long distances to get water from public annual death rate for typhoid fever in the cities of taps; or, worse still, they are supplied by tank trucks over 8000 population in the Registration Area was or water vendors.Others, especially in the smaller 34.6 per 100 000.In some cities it not infrequently towns, have to get their water from unprotected wells rose to over 100.By 1915 the rate in all the cities orpollutedstreams.Insomerecentlyswollen of the Registration Area had fallen to 11.6In 1930 African cities health conditions are often worse than it was 2.9 and by 1948 it had dropped to only 0.1.It in the rural areas from which the people have migrated, is obvious that the proper handling of water supplies largely because most of the water -supply and waste - and sewage disposal has been responsible for most disposal systems are quite inefficient.Even when a of this decrease, although some of the improvement system has existed, it has generally failed to keep pace is of course due to better methods of treating the with the growing needs.Large numbers of these disease, to vaccination, and to better general environ- city populations live outside the controlled limits and mental sanitation. use unfaced wells which are often close to latrines. Examples of this kind could be multiplied by refer- It is small wonder that the incidence of enteric infec- ence to progress in environmental sanitation in many tions is very high indeed. A great deal of infection of the world's great cities in the past generation, and by amoebic dysentery in the African towns is related in the extension of water supplies to many towns and to want of food control; and milk supplies are unsafe rural areas.Certain conditions must be fulfilled, because of the water used for cleansing, or because of however, before a supply of pure water can exercise adulteration. its full secondary effect.In the first place, it must In Latin America the recent phenomenal growth be readily accessible to the homes of the people.If a of urban areas has led to great shortages of water housewife has the choice between a contaminated supply and sanitation.In the larger cities from 10 well at her doorstep, and a standpipe in the village to 30 per cent, of dwellings are without these facilities, centre or even by the roadside a hundred yards away, and, of course, the position is much more acute in the she will choose the well, so long as its water is clear hastilybuiltslumdwellings.Many areasquite and palatable.Her choice will be fortified if the recently built are supplied " collectively " with water - public supply has been chlorinated or treated in such that is, from a water tap in a common yard.The a way as to cause an unpleasant taste or smell.She condition of small towns and villages in Latin America will also use -for washing at least -soft rain -water and Asia isoften characterized by poor housing, from a nearby tank in preference to hard water from deficient water supplies and electricity, and in many a pump down the street.The first requirement is areas by a lack of settled community life.Almost therefore accessibility. every Latin American country has introduced a low - The second requirement, which follows close on cost housing programme, but as a rule the slums grow the first,is convenience in use. A family isnot faster than the housing projects.On the other hand likelytomaintaincleanlinessreadily -of body, the health and medical care services are very much clothing or premises- unless the water is supplied better in urban than in rural areas, and quite a number by a pipe inside the house to a sink fitted with a drain. of towns show a slow fall in the indices of sickness. The maintenance of cleanliness and health is immensely For example, infant mortality rates during the past ten eased if there is some means of heating water in the years in Mexico City, Sao Paulo and a number of house. other crowded areas have fallen for the first time In the greater part of the warmer climates of the below 100 per 1000 live births.Many of these cities world provision of this kind is hardly more than the have also shared in the general decline of mortality shadow of a dream.In the colder zones it comes from tuberculosis.There is no doubt that the chlor- near to being a necessity of life.In the economically ination of water supplies,vaccination campaigns, less developed countries the present position is far the use of DDT, the expansion of medical services from encouraging.There are wide variations in the and health education have all contributed to this extent to which cities are providing safe water.Most material improvement. of them have at least limited piped supplies protected The striking contribution which the countries of by chlorination, but there are many towns in the the Eastern Mediterranean have made to the health of 10 FIRST REPORT ON THE WORLD HEALTH SITUATION their peoples during the past decade or so has been Australia and New Zealand, correspond more closely in the conquest of major epidemic diseases.There with those in countries economically comparable in have been notable victories over cholera, but the the north than with conditions in South -East Asia, most sustained progress has been made against although migration tothecitiesiscausing some malaria.Village and small -town populations are anxiety in town planning. still gravely hampered by debilitating endemic diseases A slum has been defined as " a residential area which can be cast out only by a marked improvement occupied predominantly by poverty- stricken people in housing and other environmental conditions and living in housing which is so deteriorated, so sub- by the widespread impact of health education.There standard, or so unwholesome as to be a menace to is an urgent need to train and employ far more medical, the health, safety, morality, or welfare of the occupants nursing and auxiliary personnel. and the adjacent community ".1The most important South -East Asia is an immense area in which the factor in the creation of a slum area is poverty, which variations in culture and tradition and in land and drives people into low- standard housing and so climate are so great that it is hard to generalize.At exposes them to the depressing influences of structural the same time there are certain broad influences decay, lack of environmental services, and, as a rule, affecting the health of the peoples that can be woven gross overcrowding. into a common pattern.On the environmental side the position has been complicated by the phenomenal growth of population during the past two decades: 3. GENERAL INFLUENCES Calcuttahasgrown from1 197 000inhabitants in 1931 to 2 548 677 in 1951; Delhi from 348 000 to Social, educational and cultural background 1 191 104, and Karachi from 248 000 to 1 009 438 in the same period.And so the tale is being told with In the brief reviews of individual countries which ever -increasing urgency.Malaria still holds the first are included in this report an attempt has been made place as a maker of poverty, depression and chronic to provide an outline of the social, educational and ill- health of body and mind.The control of tubercu- cultural background of the people.Itis virtually losis is rendered difficult on account of the poverty impossible to give indications of progress in terms of of the people, their wretched housing conditions, lack figures except in rare instances.Social conditions of sanitation and open spaces such as parks, and have to be judged in relation to their setting and overcrowding in both town and countryside. whether this is an agricultural or primarily an indus- The association between bad housing conditions trial one.It is abundantly clear that one of the most and the people's health is less obvious in the warmer urgent matters to be studied on a world basis today is regions than frank disease and malnutrition.Lack urbanization.From a health point of view, the of shelter does not produce immediate suffering, and movement from rural to urban conditions requires even overcrowding is mitigated by the fact that many both a mental adjustment to the rapid change in the activities are normally carried on in the open air. way of life and a physical adaptation to changes in Bad housing conditions are widespread, and there are housing, distance from work, methods of transport- broad, serious effects of crowding, want of ventilation, ation, and so on. noise,dirt and infestation which deservespecial attention. Hindrances to social progress In the temperate and colder climates of the world, environmental and housing conditions are on the The greatest hindrances to social progress- disease, whole better than in the tropical and subtropical ignorance and poverty -are being attacked by govern- regions.One obvious reason for this is the funda- ments throughout the world with increasing vigour. mental need for warmth and running water, as well When conditions are estimated by the usual indices as for reasonably solid housing construction.These it is apparent that many of the diseases that cause conditions are faithfully reflected in good general sickness, misery and economic loss are already coming health, low infant mortality rates and reasonable under control. freedom from the common infections and endemic As regards ignorance, general advances have been diseases. A distinctivefeatureofthenorthern shown recently in an imperfect way by estimates of countries is imaginative planning of towns and their surrounding districts, and theeffectivecontrol of 1 GRAVES, L. M. & FLETCHER, A. H. (1941) Enforcement and subsidy in the control of slums. In: American Public unauthorized construction of every kind.Environ- Health Association, Committee on the Hygiene of Housing, mental conditions in some southern countries, such as Housing for health, Lancaster, Pa, p. 28 INFLUENCES AFFECTING THE HEALTH OF THE PEOPLES 11 illiteracy.Fundamental education,ontheother with the use of atomic energy.Fortunately, scientists hand, is introducing knowledge and skill in practical themselves have been awakened in time to the risks living before regular schooling is established. deriving from radiation -for example, the contamin- The advance against sheer poverty has been very ation of the environment by radioactive material and uneven, although the world has made great strides in theoccupational exposure of certaingroups or both industrial and agricultural production.In the workers, such as atomic energy workers, doctors, less developed areas, however, progress has been radiologists,dentists and nurses.Possibleinjury hampered by the rapid increase in population, the from an unnecessarily extensive use of x -rays and distractions of war, and the uneven balance between other types of radiation for the diagnosis and treat- industry and rural occupations. ment of disease has also received its share of consider- Social security measures, better provision for condi- ation. tions of work and various improvements in the general The machine age has produced many other troubles welfare have had less effect on isolated and impover- that are only gradually being appreciated, such as the ished rural groups.But there is a growing recognition emission of noxious gases, the production of " smog ", of this anomaly and many governments are making the general atmosphere of noise and bustle and the a new effort to deal with it, partly by improved agri- increasing strain of city life.What has been learned cultural measures, partly by providing better condi- in the countries which became industrialized at a tions of land tenure and partly by a general advance relatively early period can and should be applied to in health and social security. nations which are only just entering the industrial phase.The " assisted take -off " by which a number of countries are likely to pass into their own industrial Cultural effects based on traditions and beliefs era ought to carry with it a thorough knowledge of The struggle against disease, ignorance and poverty the social and cultural hazards that accompany too has been retarded by the persistence of superstitious rapid mechanization. beliefs and practices.The association of disease with an offended deityis an almost world -wide Rural and industrial communities: standard of living example of this, and substitution treatments are still maintained many advancing communities.The The rural community.It has been that it path from magic to medicine has often been slow and is not so much the change from rural to industrial difficult. life that upsets the balance of persons and commu- The introduction of machinery has often been nities, but rather the stresses involved in making the resisted partly on the ground of its breaking of ties necessary individual and family adjustments to the and customs.In more recent years, opposition has new conditions,especially when the development developed largely on economic grounds, especially takes place in the rapidly growing industrial cities. when the machinery tended to supersede traditional In the older and simpler communities support for handicrafts in the home.In this case the fear of the aged and the sick, the mentally sick and the ment- poverty through unemployment has generally been ally handicapped, is generally found within the village the main consideration. community. When migration to the cities occurs, Adjustment to the machine age is a long process of these facilities, simple though they be, are lost, and social education.Some of the most urgent social there is often an unhappy time -lag between the period problems and needs of the present time are not of of that loss and the acceptance of responsibility by long standing but are associated with the very process the government.Every government isstruggling of change and development.Inall parts of the with these difficulties, but the transition from simpler world men seem to know more about the production to more complex organization, from lower to higher of machines than they have yet learnt about the effects standards of living, is a difficult process which requires that these machines will have upon their culture and all the available resources of a people. their health. In some ways the relation of health to the standard of living is a very direct one.In agriculture, for example, mass disease in the rural population means More recent problems a reduction of manpower.In 1942, for example, In this age of machinery and atomic energy, the there were at least two million cases of malaria in impact on health of technological discoveries has, at Greece.In 1949 there were 40 000.The scientific times, been considerable.One of the most striking operation against malaria resulted in a saving of problems is the one which has become associated working days per man which was the equivalent of 12 FIRST REPORT ON THE WORLD HEALTH SITUATION
adding between 100 000 and 200 000 workers a year. workers are employed in dangerous or unhealthy These estimates do not, however, reflect the darker occupations. shadows of this picture.Not only are days lost through manifest sickness from malaria and other The maintenance of employment.The maintenance diseases, but even the relatively minor infestations of full employment is a matter of the utmost import- ance to governments in the rapidly developing coun- which do not cause actual absence from work -or at tries. least only occasional absence -constantly produce In many countries undergoing industrialization depression and inefficiency and in every sense limit the only unemployment is that which results from change of occupation and not from lack of available capacity for work.One of the first effects of a work. successful campaign against disease is not only an Seasonal fluctuations do occur, but not to the same extent in industry as in agriculture. increase in working capacity but a direct increase in interest and active co- operation on the part of the Migrants.The condition of migrant workers is people. always less satisfactory and may involve great hardship In the past quite a number of countries have been and mental strain.The difficulties include housing, hardly aware of this great burden of lethargy and education and, on occasion, inequality of treatment. mental sickness until the introduction of mass attack on disease practically changed the character of the Child labour.The minimum age for employment people and made them much more effective as citizens is usually between 12 and 16 years.In areas where there and members of both the local and the national com- is a great deal of family poverty, many children are munity. employed in villages and rural districts as early as Agriculture is essentially an occupation with peaks five or six years of age.The inflexibility of this of activity requiring a great deal of flexibility in the situation has given rise to two attempts to mitigate use of labour.One of the hazards that applies to the evil:first, the offer of certain forms of social conditions of employment on the land is the compara- assistance through the schools, or family allowances, tive lack of security.Droughts are all too common in and, secondly, experiments with schemes of what is the subtropical regions of the world; floods are an called practical education, which enable the children, even worse threat to crops and stock and, in India while attending school, to contribute to some extent and China particularly, are a serious hazard to agricul- to their own support. ture and other industries.Disease of plant and Women's work. A considerable proportionof animal life is itself a great cause of insecurity, espe- agricultural labour in Asia and the Eastern Mediterra- cially where there is no developed system of quarantine nean is represented by women working for their or notification; and, finally, the want of storage and families on the land.In industrial areas of all kinds transport facilities often results in a failure to dis- there is a substantial percentage of women engaged tribute agricultural produce while it is still in good in part -time or whole -time industrial employment. condition for sale. In countries where industrialization is in process, special regulations have sometimes tended to keep The industrial community.Industrial conditions women out of factories, where conditions are relatively have now become stabilizedin many countries. good, and to leave them in unregulated jobs, where Hours and conditions of work, the welfare of workers, conditions are almost certainly much inferior and compensation for sickness and injury, the provision wages are smaller. of facilities for recreation and holidays with pay are One of the less unsatisfactory means of adjusting now well established. this balance is to provide special priorities in the Itis much easier to create stable standards of social and health services, and there is a widespread living in the large, highly mechanized factory than in feeling that maternity protection should be borne by the small industry or handicraft jobs.In many of the community. the less developed countries of the world cottage industries are far in the majority.This applies to Standard of living.There are many special pro- many large and populous areas of the world, such as blems related to the standard of living.The first and India.One of the inherentdifficultiesof small the most obvious is insufficient income, which may industry is that of control by inspection, and this arise through sickness or economic difficulties, or, as applies to both health and other conditions of work. is only too frequent at the present time, an increase In principle, as a matter of both health and fairness, in the cost of living.The depression of living stan- the eight -hour day has been widely accepted, and a dards has given rise, at the instigation of many govern- further reduction is frequently permitted where the ments, to a number of socialservices,including INFLUENCES AFFECTING THE HEALTH OF THE PEOPLES 13 insurance arrangements, compensation, provision for introduced in more than 30 countries and a pension pensions, etc. is assured in many. Persons under disability.Problems of the handi- Diet and family budget.Family budgeting is a capped raiseseriousissues,especially when the matter of great importance.The main difficulty handicap involves either a total inability or a limited arises from the fact that budgeting is,at best, a capacity for work.Blindness in some societies is a complicated and difficult process.The purchase of matter of great gravity, and a good deal of it could food and other goods often follows traditional lines have been prevented by timely health measures. and is not related by the people themselves to their Finally, old age has begun to take its place in social immediate needs. A poor diet may be the conse- organization.From time immemorial non -industrial quence of traditional eating habits and beliefs and communities have been traditionally responsible for partly due to sheer poverty.It is clear that any hope the care of their own aged.In modern industrial of improving the standard of living in terms of diet communities certain difficulties have arisen, partly depends on educating the people in healthier practice owing to the increased expectation of life.In addi- and in estimating the best budgeting on the available tion, the lack of domestic help and the small house income. A low standard of living is the end -product accommodation have added tothedifficulties of of a vicious circle, poverty leading to malnutrition families in caring for their own aged relatives.For and eventually toill- health, which aggravates the these reasons compulsory old -age insurance has been initial poverty. CHAPTER 2
THE STATE OF THE PUBLIC HEALTH
1.THE MEASUREMENT OF HEALTH the various components of living representing values which could be expressed quantitatively).Among One of the fundamental questions to which an the components suggested, " Health, including demo- answer is anxiously awaited by the health adminis- graphic conditions " appears first in that list.This trator is : How should the state of the public health be indication has set health workers thinking on how measured ?No satisfactory answer has yet been put best to devise suitable measures for the state of the forward.Indeed, the problem isdifficultin the public health. extreme because we do not yet know how to assess The definition of health is wide, embracing physical, objectively the state of health of even a single individual mental and social well- being.While health statisti- in the community." Health ", said Galen, " is a sort cians have devised several indices to compare some of harmony ", not a fixed quantity but one changing of the negative aspects of physical health, it is to be as the quality of nature changes from birth onwards. noted that so far no suitable index has been put Equally true is it of the health of population groups forward toqualify thestatus of a community's or nations which, from younger age -structures in the mental health or its state of social well- being.Indeed, less developed areas or countries, have passed or are a study of the health and demographic component of passing into population structures with a preponder- levels of living raises several difficult and as yet ance of the aged.Furthermore, the term " health " unsolved problems, demanding an examination of the conveys something like the meaning of " wholeness " many elements of the health component itself.For since, if the individual is to be healthy, every part or example, the various health statistics in current use unit of which he is composed must also be healthy have been separated into three groups: and capable of meeting the demands made upon him. As Haven Emerson put it," We see two healths: (1)those associated with the health statusof that of the individual and that of the community; persons and populations belonging to a given area; i.e.,personal and social health,necessarily inter- (2)those relating to physical and environmental dependent but not wholly synonymous.These two conditions having a more or less direct bearing on the healths remain distinct, not identical, social profes- health status of the area; and sional and intellectual experiences and administrative (3)those concerned with health services and acti- disciplines ".1 vities directed to the improvement of health conditions. In the post -war years considerable interest has been shown in the study of the problem of measuring Within each of the above three classes one might seek levels of health.This question has arisen from the indicators for different aspects of the problem on the requirement, under the Charter of the United Nations, principle that comprehensive indicators would be of that the United Nations shall promote higher standards great value both for international comparisons and of living.How isone to measure whether the for the assessment of changes over a period of time standard of living or level of living of one community within a given area, supplemented by appropriate is higher or lower than that of another, and whether special indicators of various types and levelsof the level of living for a community is showing improve- aggregation.On the available evidence it is hardly ment ? So far no single index or measure of the practicable to recommend categorically any particular standard or level of living has been accepted, and it comprehensiveindicator,but thefollowing were is suggested that the problem should be approached suggested as possibilities: in a pluralistic manner (i.e., by considering separately (1)Percentage of deaths of persons of 50 years and over in relation to the total deaths.Using 50 years as 1 EMERSON, H. (1953) The meaning of health in public health. In: GALDSTON, I., ed. The epidemiology of health, New the limiting age, it is clear that, hypothetically, if all York, p. 154 persons lived to 50 years of age, the index would - 14- THE STATE OF THE PUBLIC HEALTH 15 be 100; if, on the other hand, no one reached that and elsewhere receiving a piped supply in relation to age, the index would be zero.The primary data are the total number of people, the extent to which water comparatively simple to collect and the method of supplies are purified and the general adequacy of construction is straightforward.In the less developed supplies.This information brings far greater response countries there is a preponderance of persons under 50, and is obviously far more accurate than any returns and accordingly the percentage of deaths at 50 years on the extent to which the water -carriage system is and over is lowered.This " proportional mortality used for sewage disposal, the methods of dealing indicator " has many advantages over the remaining with refuse and other waste material, and the pollution indices. of rivers. (2)Expectation of life.This is a comprehensive In addition to this it might well be possible to figure but, because it is related to censal periods coming devise an index of the level of housing and even of as a rule at ten -year intervals, its usefulness is rather town and country planning which would give satis- limited in public health administration.The index factory data about positive health.This information is available at present for only a small number of has been presented by a considerable number of countries. territories in which industrial development has not taken place so far, but it has not yet reached a stage (3)The crude death rate.This rate is conditioned which would permit accurate figures to be compiled. by age and sex distribution, yet in spite of this limita- tion death and birth registration may be the only sources of data accessible in a large number of 2.SOURCES OF STATISTICAL INFORMATION countries. It is widely agreed that the expectation of life at Until a decade or so ago health administrators birth, at one year, or at any other age quoted is generally had recourse to two major sources of theoretically thebest indicator;butitissorely informationfornumericalstudyof community restricted to a few countries and to infrequent inter- health problems : vals.Forpracticalpurposesthe" proportional (1)Legallyregistrablerecordsof vitalevents, mortality ratio " offers the greatest possibilities in such as births, deaths, marriages, etc.From these this range. have been derived fertility as well as mortality rates, Of the specific health indices the infant mortality by age, sex, geographical area and cause of death. rate is valuable.This is especially true of the period One of the most commonly used yardsticks of health from one to eleven months, because it is less influenced -namely, the infant mortality rate -was obtained by pre -natal and intra -natal causes of death.On the through these sources, and in more recent years other hand, it would not be so widely obtainable as refinements and progress in the method of recording the ordinary infant mortality rate. causes of death have permitted the carrying -out of The value of the death rate for communicable special studies on individual disease problems, as well diseases is limited because medical certification is not as the separate examination of neonatal and perinatal reliable in many parts of the world.The total death mortality.Such indices as expectation of life or the rate in the 1 -4 age -group might be a useful special number of productive years of lifelost through indicator where accurate age- recording justified its premature death have also been derived from these use. sources. The indicators mentioned above, with the partial (2)Thenotifiable- diseasereportingsystemis exception of the first,are, on the whole, negative primarily established for controlling the spread of indices of health. It would be of great interest and infection and giving relief to the person affected; and importance to secure some readily obtainable indi- it has accumulated a good deal of valuable epidemio- cators of positive health. The question has been logical and statistical information by which preventive widely canvassed but so far no indicators that will measures could be improved and current epidemiolo- give a broad picture, yet with sufficient detail, have gical records of the history of these diseases built up. beenagreedupon.Considerableadvanceshave been made, however, in the study of physical and These data belong to the broad field of sickness in environmental conditions and their bearing on levels the community, but have never been regarded as a of health.One of the most interesting on which reliable index of the level of total sickness, firstly, information has been secured from the returns of because the number of diseases for which information a surprisingly large number of countries is the water is notified is relatively small in comparison with the supply.This includes the number of people in cities whole multitude of diseases, communicable or other- 16 FIRST REPORT ON THE WORLD HEALTH SITUATION wise, affecting the community; and, secondly, because be included, viz: (a) all sickness at one point of time; in its operation the notification system is defective (b) all sickness during a given period of time; (c) se- (for example, for some diseases only a minor fraction lected diseases at a point of time and (d) selected of the total occurrences is brought to the notice of diseases during a given period. the health administrator). Among the various kinds of morbidity statistics a In view of the growing recognition of the need to few important ones only can be considered in some assess the state of ill- health in relation to the economic detail, with special reference to their range of useful- and social well -being of the population, there is an ness and their advantages and deficiencies as sources increasing desire to obtain a deeper understanding of of information on morbidity. the total sickness experience of the community. We need precise information on how many persons fall sick in each age, sex or occupational group, how Sickness surveys frequently each person is sick, for how long, how With the object of obtaining the maximum informa- severely, and from what diseases.One requires to tion through sickness surveys many local and national know also how much is spent on the care of the sick studies on morbidity have been undertaken in the and what are the yet unmet health needs of sick past.The experience so far gained in the United persons in the community.The desire to obtain States of America, Canada, England and Wales, information on these aspects has opened up a broad, Ceylon, Denmark, and Japan has made it abundantly highly complicated field of morbidity statistics, but clear that the survey method, covering either a whole it is the one in which considerable advances are being population or more usually a representative sample made.The problems being tackled are those of of it,is a promising method for obtaining various arriving at suitable definitions and terminology as types of health statistics.It also broadens the inter- well as of administration -that is, devising ways and pretative base for morbidity data obtained by other means of obtaining the required information accord- means and contributes to planning health services ing to set plans, especially by sampling procedures. and health programmes.The survey method is not As an initial step, the following broad classification only widely applicable in the more advanced countries, of countries by stage of development has been adopted, but may also be employed effectively in countries no attempt having been made to allocate individual where the possibility of obtaining morbidity data from countries within this classification: registration or record systems is extremely limited (1)countries with no complete enumeration of and where the same organization could be responsible population and more or less deficient in public health not only for the planning of health services but also and vital registration systems; for conducting morbidity surveys tofurtherthis object. (2)countries with a complete or partial census Among the advantages of the survey method are and with a well -developed public health and vital the following: registration system for parts of the population (e.g., for large towns) but not for all areas; (1)it makes it possible to link morbidity data with a variety of social and economic conditions; (3)countries with a complete census and well - developed facilities for obtaining morbidity statistics. (2)the population covered is automatically defined; The sections of the population within a country or (3)it offers a means of linking the data in existing area that would be covered by different methods of medical records with those obtained from the general morbidity ascertainment are as follows: population; (1)whole population of country (or representative (4)if probability sampling methods are employed, the information can be obtained with precision at the sample of it); smallest possible expense; (2)population of selected locality (or sample of it); (5)the method is flexible and can be utilized to (3)selected types of persons in whole population provide answers to a wide variety of questions of (or samples of them); practical administrative as well as scientific import- (4)persons applying to selected health services; ance; and In addition, it is necessary to classify morbidity (6)if the objects of the investigation are not according to the periods of time covered by any continuous, once the specific aim has been satisfied particular method of ascertainment and according to the survey can easily be stopped and the trained staff whether all conditions or selected conditions would turned to investigate other problems. THE STATE OF THE PUBLIC HEALTH 17
The survey method requires the services of experts both as sources of general morbidity statistics -as a in sampling theory, in the planning and operation of means of carrying out longitudinal studies on fami- field surveys, and in the analysis of morbidity data. lies -and toobtainstatistics on specialdiseases. This source provides information about the incidence Census enumeration of certain defects of disease and injury as seen in general practice in The data obtained by this method are in many relation to the sex and age of the patients.It also cases underestimates of the real incidence of such supplies data about the proportion of these illnesses which give rise to admission to hospital for in- patient defects within the community; but in certain countries where such defects are widespread, and where no care.Some practices provide information about other sources of relevant statistical information are the occupations of patients as a basis for studying available, census enumeration could be useful. morbidity in relation to occupation.
Notifiable communicable diseases Social security and national health insurance records As has been stated already, information collected Social security records are among the oldest sources through notification systems in variouscountries of morbidity statistics.Although they have been prevents accurate comparisons of the real incidence used for this purpose for many years, their use has of the disease; the incompleteness of notification not until lately been anywhere on an extensive scale. affects to a varying and sometimes high degree the They could provide useful information on sickness value of statistics of infectious diseases.The degree connected with certified incapacity, particularly in of incompleteness varies considerably between differ- regard to morbidity rates, seasonal variations, and ent diseases, between different countries and parts of occupational distribution.In a number of countries, the same country and from one period to another. such as England and Wales, France, Germany, Italy, Furthermore, the criteria by which these diseases may Norway, Portugal and the United States of America, be defined in various countries for the purpose of the national committees on vital and health statistics notification and the variety of procedures used for are actively engaged in studying the utilization of correcting diagnoses and avoiding duplication of these records. notification detract from the value of these data. Itisto be emphasized that insurance statistics provide information on the sickness of a selected Hospital in- patient and out -patient records population, and the sickness reported is of a special It is generally agreed that hospital case records are kind -that which causes absence from work, usually important sources of morbidity statistics because they for a minimum specified period.Insurance statistics are actual or potential archives of precise and compre- do not therefore provide morbidity or mortality data hensive diagnostic assessments of laboratory and representative of the total population, but, within autopsy findings, and of information about the past the limits described above, the information does cover a wide range of sickness reported in a routine manner medical history of the individuals concerned. Diffi- culties of interpretation arise, however, because of the among a large group of people. highly selective character of hospital morbidity data, and generalizations about the population from such Records of health and welfare centres and educational selected material are difficult because the amount and institutions direction of biasisnot known.The population Records of medical examination at health and exposed to risk is also not known.Nevertheless, mor- welfare centres and educational institutions (including bidity surveys can provide a useful link between the colleges and universities) constitute an important general morbidity in the population and the selected source of morbidity statistics.There is the additional morbidity treated in the hospitals.For some areas possibility of making use of these records for follow -up of the world, hospital records may be the only source studies of the physical development of children and of information, and, provided due caution is used, a of the progress of defects and diseases. good deal of knowledge of the prevalence of sickness in a community can be obtained from them. Records of sickness absenteeism in industrial, civil General practitioners' records service, and other occupational groups Attempts have been made, especially in the United Morbidity statistics from this source also possess Kingdom, to utilize general practitioners' records, considerable value.But there arepitfallsin the 18 FIRST REPORT ON THE WORLD HEALTH SITUATION interpretation of these records, mainly because sickness 3.TRENDS IN THE STATE OF HEALTH absenteeism, even when medically certified, is influ- OF VARIOUS COUNTRIES enced by many extraneous circumstances. IN THE COURSE OF DEVELOPMENT With the progressive development of countries Sickness and recruitment records of the armed forces there has been a general trend towards the improve- The sickness and recruitment records of the armed ment of their state of health.This has been particu- forces could be utilized as sources of morbidity larly striking in the decline of infant mortality and in statistics, with reference to :(a) obtaining data on a the increase in the heights and weights of growing cross -section of persons in young -adult age -groups children, due no doubt to a rise in the standard of classified by degree of physical fitness and according living and to a general improvement in nutritional to body measurement; (b) having continuous mor- status.In many countriesthesteadyadvance bidity data on this particular section of the popu- towards the conquest of some of the most serious lation; and (c) preparing follow -up (longitudinal) and widespread communicable diseases has been a feature of recent development.Nevertheless, indus- studies. trial progress, now as in the past, carries its own risks, especially when the speed is abnormally high. Use of sampling techniques in measurement of health The movement of people in the direction of new sourcesof employment requirestobecarefully It has already been shown that in some surveys, watched, in case it should outrun the capacity for instead of covering the entire population, a sample planning. alone is studied.Indeed, for large populations a Overcrowding of families in cities is a danger to total coverage is generally not expedient because of healthin an immediate physicalsense.As the the prohibitive cost involved, the want of trained populations of countries increase, there is a growing staff, and the long waiting period before the entire movement from rural areas to towns.This is greatly mass of statistics can be analysed.When there is a accelerated when rapidindustrialprogresstakes need for quick but elaborate information on various place.Unless careful and far -sighted planning is items of health at frequent intervals, the use of sam- undertaken in good time, health conditions deteriorate pling techniques is preferred. We can obtain more progressively with urban growth, as was evident in accurate information on the population with a few the great industrial cities and manufacturing towns reliable, trained investigators working on a properly of the West European countries in the 19th century. selected sample than would be possible with a large It may be said in general terms that before the 20th team of untrained investigators employed on a full- century health conditions throughout the world, as scale survey.There are, of course, certain items of reflected in general and infant death rates, were worse information which cannot be got from examining a in urban than in rural areas.What is more, these sample, but then we must balance the probable conditions in the crowded unplanned cities actually inaccuracy of the sample against the economies deteriorated as time went on, until strong environ- effected.The errorassociated with an estimate mental health measures were taken.The inhabitants obtained from a sample can be calculated, and we of crowded areassuffered more from recurrent can then decide whether or not we are prepared to epidemics of the major diseases like cholera, plague, accept the error.For this reason, in almost all yellow fever and smallpox than did their rural neigh- branches of statistical studies on human populations, bours. sampling procedures are gradually replacing complete Since the beginning of the present century a remark- surveys.In the recent past, considerations of accuracy able change has taken place in the more organized and of keeping down the cost have led to rapid industrial towns, to such an extent that in the majority advances in the technique of sampling and in the of those countries for which reliable data are available standardization of methods and terminology.Con- the general levels of health are rather higher in the siderable interest in this matter has been shown at the major cities than in the country as a whole.This internationallevel,and certainrecommendations improvement has been due in the first instance to the have been issued for the preparation of reports on great advances in environmental sanitation which sampling surveys and for the standardization of took place towards the end of the 19th century, and terminology soastoensureclarity,comprehen- in the second place to the rapid developments in the sivenessandinternationalcomparabilityinthe personal health services which are an outstanding reports. feature of the present century.Unfortunately, the THE STATE OF THE PUBLIC HEALTH 19 evidence suggests that the changes for the better are As time goes on, more and more governments are ill -distributed.In the less developed countries which realizing these dangers and are taking measures to are now undergoing rapid urbanization, environ- prevent them.The medical care services in cities are mental advances have frequently failed to keep pace improving, and there is a healthy, growing demand with the needs of the growing population, and personal for them.The ever -present dangeristhat these services have lagged far behind.There are indica- services will fail to keep pace with the march of urban tions that the community programmes of rural areas development and progressive industrialization.The will soon catch up with the town services in efficiency loss of employment from sickness may readily cripple and in their combined contribution to health and an industrial development. welfare.Without doubt the unfavourable state of In summary, it would be fair enough to make a the growing city populations is due in part to sheer generalization by saying that the well -being of coun- lack of financial resources and the high cost of environ- tries in the course of development at the present time mental sanitation in congested areas.But there are depends on a number of conditions which at best other elements.In many cases the health needs have reinforce one another.These are as follows: been positively crowded out by the industrial scramble, (1)Industrial development issufficiently orderly and what ought to have been well -planned services to to permit a parallel increase in the social and health promote health and prevent sickness have now become services, both personal and environmental. costly and less efficient attempts to remedy harm already done and to restore what should not have been (2) The growing population is absorbed by industry sacrificed.The result in a large number of the urban in a steady flow and does not flood the area. areas of the less developed countries is that disease (3) The incoming people are ableto provide and chronic ill -health still impose an enormous and themselves, or areprovided with, good low -cost unnecessary burden of cost, misery, maladjustment housing which does not absorb too high a proportion and wasted productive power. of their income. Some causes of ill- health have been more prominent in rural than in urban districts, and are actually (4) The incoming population contains a good pro- brought to the great towns by rural immigrants.This portion of strong and capable workers and is not is broadly true of trachoma and a number of intestinal overwhelmed by economically low -grade and ill - parasites.Other diseases, such as malaria, bilharz- nourished immigrants, whose occupation of areas is a iasis and yaws, tend to diminish more quickly in the burden on the housing and health services and so cities because of better control of vectors and, to some contributes less than nothing to the economy. extent, earlier and more effective medical treatment. (5)The resident population, as development pro- On the other hand, even apart from major epidemics, ceeds, is a well -balanced cross -section of a normal the diseases associated with overcrowding are more community, i.e., in age and sex distribution. widespread and persistent in the urban areas.Chief of these is tuberculosis, which has been shown to (6)There is a reasonable prospect of regular, as spread more widely in the congestion and dirt of slum opposed to seasonal or sporadic, employment for the areas than in any other environment.In addition, incoming people. pneumonia and other respiratory diseases are more (7)The arrangements made for immigrants include prevalent in the cities and are apt to be associated reasonable working conditions under well- enforced with a larger number of deaths from complications. regulations, proper hours of work, and an absence of The intestinal diseases spread by contaminated food exploitation, especially of women and children. and water are also found more frequently among urban populations. (8)Residential planning offers opportunities for The great wave of industrial development brings community life and community activities, such as special dangers in its wake.The larger factories, and religious and social institutions, schools, shops, and those which are well -established in industrial towns, adequate transport. are increasingly subject to inspection and regulation on both health and engineering sides.In the more Reduced mortality at certain ages developed countries the provision of medical facilities is usually compulsory.In the growing industries, As has been shown, there are important tests of however, and especially in expanding small factories healthy and ordered development.Among the signs and workshops, protective regulations are much less of progress, a considerable number of countries have common and are difficult to enforce. been able to show a declining general death rate and 20 FIRST REPORT ON THE WORLD HEALTH SITUATION a striking fall in infant mortality.In addition to malaria still constitutes a public health problem pro- this, the reduction in endemic diseases and the decline grammes of control are now being carried out; indeed, in the common infections have been demonstrated by in regions other than Africa most countries have a welcome diminution in death and disablement in introduced nationwide schemes.In six countries of the age -group 1 -5 years. Asia -Afghanistan, Burma, Ceylon, India, Indonesia, Itis perhaps hardly necessary to draw further and Thailand- recent estimates indicate that control attention to the remarkable and widespread reduction programmes have alreadyprotected121million in infant mortality, especially in the period from 1 to people out of the 250 million living in malarious 12 months, and to point to its association with the areas.Pilot projects have been started in a few steady improvements in both environmental and countries and territories of Africa, including French personal health measures. Successful campaigns West Africa, French Cameroons, Liberia, Nigeria, against the great scourges, such as malaria and and Tanganyika.The main object of these schemes tuberculosis, have improved the prospects of life and is to collect information for planning large -scale anti - health both in childhood and in early adult life. malaria programmes.In some instances a fresh Reduced mortality in childhood first became notable approach has had to be made because in certain in economically advanced countries with the conquest districts anopheline mosquitos are developing resist- of some of the commoner infectious diseases and the ance to insecticides.Nevertheless, practically com- reduction in the killing powers of others.This has plete eradication of the disease has been secured in been most clearly demonstrated in scarlet fever and Italy, the United States of America, British Guiana diphtheria, as a result of modern methods of treatment, and French Guiana, large areas of Argentina, Ceylon, and, in more industrialized communities at least, Thailand, and Venezuela.In many of the remaining measles and whooping -cough have followed the same parts of the world eradication work has been started trends.The net result is that the childhood age - and the disease has become relatively insignificant as groups have shown in the more developed countries a a health problem. remarkable reduction in both mortality and sickness. The reduced mortality from tuberculosisof the Treponematoses.It is estimated that some 50 mil- bovine type has been a very gratifying improvement lion people are infected with yaws, but its elimination in the childhood period, and in many countries the is now a practical target for all campaigns.Active steady disappearance of glandular and joint infections projects are now in operation in the Cameroons, is a most promising trend.The period of infancy French West Africa, Ghana, Liberia, Nigeria, Sierra still gives rise to difficulties and the adolescent com- Leone, and Togoland, in Africa; India, Indonesia, munity suffers still, although the prospects are very Laos, Malaya, and Thailand, in Asia; and also in hopeful.The reduced mortality in general from some of the Caribbean islands, Haiti, the Philippines, tuberculosis and the shift in the incidence of the disease a number of Pacific islands, and Netherlands New to the older age -groups have been remarkable develop- Guinea.These campaigns are in different stages of ments, although one must remember that modern development in the various countries, but they have treatment has in many cases reduced the deaths already achieved a substantial decrease in the preval- without affecting to the same extent the prevalence of ence of clinical yaws.Nearly 90 million persons the disease.In many parts of the world communic- have been examined, and 22 million have been treated able diseases still constitute an important cause of as active cases or contacts.At re- surveys of these mortality and morbidity but the general trend is populations it has been found that clinically active towards steady improvement, especially in the younger yaws has fallen from an average prevalence of about and more susceptible ages. 10 -12 per cent. to 1 per cent., and in some areas no active cases whatsoever have been discovered.This means that the transmission of the disease has largely Reduction in mortality from certain diseases come to an end, so that, while the progress of the Malaria.One of the most remarkable improve- disease has been checked in persons infected when the ments in the world health situation has been due to campaign was begun, new infections have been very the widespread control of malaria.As a rough few.The future extension of the campaign against approximation it may be said that today's figures of yaws, now that most areas of high prevalence have prevalence and mortality are half what they were been covered, will carry the work into the less affected twelve years ago: the present number of deaths stands districts, where some adaptation of technical policy at 1.5 million and the total number of cases at about will no doubt be required.The importance of 150 million.In practically all the countries where adequate provision of rural health centres in the THE STATE OF THE PUBLIC HEALTH 21 supervision of yaws, until eradication is complete, is Trachoma.Itisestimated that trachoma and apparent. infectious conjunctivitis affect no less than 400 million The battle against endemic syphilis is proceeding people.They present a grave social problem because in Bechuanaland, Iraq, and Syria; and it has achieved of the high percentage of blindness they cause.The almost complete success in Yugoslavia.The preval- percentage of trachoma infection among children can ence of venereal syphilis has for some years been be very high, and in some territories of North Africa relatively low in the more developed countries; and it often reaches as much as 70 -90 or even 100.In in fact the reduction in antisyphilitic measures in other territories of Africa, evidence during the last some of these countries has led to a slight increase few years has shown that trachoma is a more important in the number of new infections.In the less de- problem than it was hitherto believed to be in certain veloped countries syphilis is largely an urban disease. areas of French territories in West and Equatorial Its prevalence has decreased since the introduction of Africa, Ghana, Kenya, and South Africa. A very penicillin, but more accurate information about the high incidence has been detected in several areas of extent of infection and more active control measures the Eastern Mediterranean as well as in regions of are necessary.Internationally assisted campaigns are Iran, India, Indonesia, and China, in Asia. at present being undertaken in Ethiopia, Iran, Mo- Recent epidemiological investigation has shown rocco, Pakistan, Spain, and Taiwan. that the disease is present and may also reach a high incidence in some areas of Western Australia, Papua, Bilharziasis.Bilharziasis is of great health import- and various islands of the Pacific. ance to the world because of its very wide distribution The diseaseisprevalent in some countries of and also on account of the socio- economic aspects of South America and has been shown to exist among the disease.Wherever it occurs it is a handicap to Indians in certain districts of Central and North economic development.Specialeffortsare now America. being made to secure control.Surveys have been In Europe, trachoma still exists in many countries, made in Africa, the Eastern Mediterranean, and in particularly in some areas around the Baltic and some areas of the Western Pacific, and control projects Mediterranean shores, and isstill a public health have now been established.Further special research problem of considerable importance in certain areas to find a more efficient drug applicable to mass of Spain and Yugoslavia. treatment, and on chemical molluscicides with a The bacterial types of conjunctivitis (mainly those stronger residual effect,is needed to improve the produced by the Koch -Weeks bacillus), which may efficacy of present measures for the control of bil- cause blindness and other complications in themselves, harziasis. produce yearlyepidemics and areassociatedin varying frequency with trachoma in the different Onchocerciasis. A good deal of progress has been countries.This association prolongs and makes the made in the control of this disease, which affects evolution of trachoma more severe. nearly 20 million people in tropical Africa and is Local treatment by several antibiotics has produced prevalent also in Central and South America.Effect- very satisfactory results, and mass treatment campaigns ive methods have now been developed for fighting have been successfully started and are in progress in both the parasitic worm and the insect vectors. Morocco, Taiwan (China), Tunisia, Egypt, Spain, Successful campaigns have been carried out against Yugoslavia, Indonesia, and India. onchocerciasis in Guatemala and Mexico to reduce, by surgical removal of the nodules, the incidence of Leprosy.The satisfactory results obtained in the blindness and other disabling eye lesions. treatment of this disease and the realization that only Mass treatment campaigns have been started in certain cases are really infectious have led to a new areas of endemicity in French Equatorial and West policy of leprosy control, which has stimulated the Africa, the Cameroons, and the Belgian Congo. ever -increasing interest of governments, international In addition, control measures against the different and national organizations, and research workers. species of the Simulium vectors, based on the use of The new policy of leprosy control is based on the insecticides against either the adult fliesor their abolition of indiscriminate and permanent segregation larvae, or both, have been satisfactorily carried out of all cases and its replacement by early diagnosis and in several countries of Africa and America.Local mass treatment carried out either at home, in out- eradicationisclaimed to have been obtained in patient clinics or in special institutions where only limited areas of the Belgian Congo, Kenya, and infectious cases are to be temporarily isolated.Wher- Uganda. ever applied, the new technique has rapidly gained the 22 FIRST REPORT ON THE WORLD HEALTH SITUATION
Date of Percentage of confidence of the affected populations.Patients, no Country census population at age longer hiding in fear of life -long segregation, have 60 and over come forward spontaneously in great numbers to ask Egypt 1947 6.0 for treatment. Mauritius 1952 5.6 The resulting increase in the number of registered Union of South Africa (white cases has confirmed the great importance of leprosy population) 1951 9.7 as a social and public health problem in many coun- Canada 1950 11.4 Guatemala 1950 4.4 tries.The total number of sufferers throughout the Mexico 1950 5.5 world is probably more than 12 million, and possibly United States of America .. . . 1950 12.2 as high as 15 million.Large -scale control measures Argentina 1947 6.6 have been started by many governments, including Brazil 1950 4.3 those of Brazil, Venezuela and Paraguay in South Chile 1952 6.5 America, and Burma, Thailand,thePhilippines, Ceylon 1946 5.4 Indonesia, India, and Ceylon in Asia. India 1951 5.7 In Africa, where the most important campaigns are Japan 1950 7.7 Pakistan 1951 5.0 being carried out, covering hundreds of thousands of Thailand 1947 4.2 patients, mass treatment is under way in territories Austria 1951 15.6 of French West and Equatorial Africa, the Cameroons, Belgium 1947 15.6 Belgian Congo, Nigeria, and Uganda.Important England and Wales 1951 15.9 control activities have also been started in Ethiopia, France 1946 15.9 the Sudan, Kenya, and Spanish Guinea. Netherlands 1947 10.7 Portugal 1950 10.5 In view of the fear and prejudice which for centuries Sweden 1950 15.0 have accompanied the name of leprosy, the social Australia 1947 12.3 aspects as well as the medical ones must be seriously New Zealand 1951 13.2 considered.In particular, the cured patients, who must not only be physically rehabilitated, wherever possible, but also receive the necessary training to Increased liability to old -age diseases enable them to earn their living in society, stand in In the economically developed areas more need of special attention. attention has had to be paid perforce to the chronic Trypanosomiasis.Many areas of Africa south of degenerative and malignant diseases.The span of the Sahara are affected by trypanosomiasis, and the life has extended, and these diseases and the general mortality and morbidity rates for this group of diseases care of the aged have become an important province have a serious effect on the productivity of African of the health authority.During recent years the territories.Methods of control by chemoprophylaxis epidemiology of many of the chronic degenerative and vector eradication have caused a substantial diseases has been carefully studied, but so far no decline in the incidence of these diseases, and the general means of prevention has been discovered. administration of chemical drugs has reduced the This group belongs essentially to the technologically death rate, but there are still many active or potential advanced countries because of the important changes endemic foci. in the age- composition of the population, leading to an increased liability to the diseases of old age.The cardiovascular diseases affect, in the main, middle -aged Changes in age- composition and elderly persons;their incidenceistherefore In the countries where industrial development took profoundly affected by age- distribution.There may, place many years ago there has been a striking change for example, be a relatively low over -all mortality in the age- composition of the population.As is from this group in a country with a high birth rate well known, the steady improvement in environ- and therefore a high percentage of young people, mental conditions in the course of the 19th century while at the same time age -specific death rates show was responsible for a fall in the death rate, and the them to be important causes of death.Thus the development of the personal health services in the general mortality from heart disease is much lower in present century still further increased the expectation the Netherlands than in Norway.(Rates per 100 000 of life at birth.In this sense at any rate one can of the male population are 306.0 and 358.8 respect- speak of the young countries and the old.Taking ively.)But mortality for men above 40 is about the the latest available figures continent by continent, same in both countries - namely, 932 and 936 per one gets this remarkable picture: 100 000 respectively.This is due to the fact that THE STATE OF THE PUBLIC HEALTH 23
young people and children constitute a much higher and territories one cannot fail to be impressed by the percentage of the population in the Netherlands. existence of some patterns among the variations.On Again it has been shown that in almost every country the whole, the northern countries of Europe are for which data are available male mortality from distinguished by a sense of fulfilment due to the steady cardiovascular diseases -in all age -groups -is higher fall in the common indices of ill- health.This has than female mortality.For both sexes there is a been no sudden change, but a regular, predictable rapid increase with advancing age.Degenerative response to a series of well -designed programmes to heart disease is now the most frequent cause of death promote personal and environmentalhealth.In in North America, in most of Europe and among the many of these countries the people themselves play more prosperous groups of the population in the a conscious part in health and educational activities. other parts of the world.This cannot be explained In the great majority of services, compulsion is far in solely as the result of the reduction of other causes of the background, but enforcement could be applied if death, or of the changing structure of the population. necessary. Some other factor must be involved, probably connec- The pattern changes, but shows many positive ted with modem modes of living and possibly with values, in countries like the people's republics, which some particular item in the diet. have adopted as part of their plans of development a The increased incidence of cancer of the respiratory programme of health and education.The Union of system has given rise to much speculation in recent Soviet Socialist Republics has had a relatively long years.The development is most striking in highly period in which it has been able to bring many of its industrialized countries.Among women the mortality plans to maturity; and the results in the health field from this form of cancer is much lower than among are impressive.Special advances, with positive results men and is also increasing less rapidly.As in deaths available to the world of science, have been made in from cancer of the lungs, mortality from cancer of the campaigns against communicable disease, notably the digestive organs is also higher among men.In the diseases transmissible from animal to man.The populations in which the expectancy of life at birth organization of medical care through a system of is high, one must also regard as inevitable an increase " hospital -polyclinic " combined units is proving to in the more chronic respiratory diseases. A good be an excellent example of the combination of preven- deal of epidemiological research is now being devoted tion and treatment, without any breach of continuity. to this subject.In England the 16 million male The USSR is the outstanding example of an exclusively industrial workers had 4 625 000 episodes of sickness State -controlled medical service, and its progress is and injuries in 1953 -54 which lasted for four or more being watched and studied with the greatest interest. days.This represented a total of over 200 million A number of other countries with a more recently working days lost.Ten per cent. of this certified formed State medical service are moving along the incapacityfor work was ascribedtobronchitis same lines as the USSR, but they have not yet had (20 million days), and asthma accounted for a further the same range of experience.Reports from such 3 million days.Rheumatism, arthritis, sciatica, etc., countries as Poland and Romania are encouraging. accounted for 17 million days, and no doubt many They show satisfactionwiththeresultsalready of these were diseases occurring in the latter half of achieved and a keen interest in further advance.In working life.In men aged between 45 and 64 years, Poland, for example, the fall in infant mortality, under the acute respiratory infections in terms of incapacity exceptionally difficult conditions, is demonstrated by for work represented about 15 per cent. of the total; rates of 139 per thousand live births in 1938 and bronchitis, 17 per cent.; arthritis and rheumatism, 71 in 1956.Qualified attendance during childbirth 15 per cent.; injuries accounted for a further 16 per was provided in 1956 for nearly 90 per cent. of mothers, cent.1 and 37 per cent. of infants under one year had the benefit of attending a clinic.Similar experience has 4. DEVELOPMENT IN PHYSICAL AND MENTAL been reported from Romania.It should be added HEALTH that in these countries stress has been laid on physical NUTRITIONAL STANDARDS education as a means to positive health, and there has been a great development in athletic activities. Developments in physical health In attempting to assess very briefly the health outlook and activities of a large number of countries Developments in mental health
1 MORRIS, J. N. (1957) Uses of epidemiology, Edinburgh, Advances in mental health do not necessarily follow p. 10 the same lines as those in physical health.There has 24 FIRST REPORT ON THE WORLD HEALTH SITUATION been considerable progress in the organization of malnutrition is a very important foundation for all teaching and in the promotion of mental health in the subsequentwork.Atthesametimedisorders community by educational and publicity methods. connected with insufficient or unbalanced food have In particular, it is satisfactory to observe the trend, in to be approached from an educational point of view, an increasing number of countries, towards closer because it is difficult to persuade people to change integration of the mental and the physical health traditional food habits, quite apart from any question services.This is well illustrated in the larger part of cost or technique.The most effective channel is taken by general hospitals in the care of early mental possibly education in nutrition through the maternal breakdowns,andinco- operationbetweenout- and child health centres. patient clinics in both mental and general hospitals. Efforts have been made recently to control and The organization of associations for the promotion eradicatepellagra.Studieswerecarriedoutin of mental health has now spread widely.On the Yugoslavia,Egypt, and Basutoland.Epidemiolo- other hand, much remains to be done. A substantial gically the disease is most frequently associated with number of countries, however, are setting up mental grossly restricted intake of food, with little variety, health programmes, and some are developing field and with a predominance of maize in the diet.The work side by side with hospital care.They are reduction of pellagra is not a gigantic problem and it beginning to speak of mental health rather than is essentially dependent on altering the diet pattern mental disorder, and this positive attitude is in itself rather than on providing any specific treatment. a good sign. This may mean a change in agricultural policy with the addition of certain special techniques.Some demonstration programmes indicated that the enrich- Nutritional standards ment of maize with niacin in the small mills was an One of the outstanding aims of world health work effective measure which could sometimes be intro- today is to achieve higher nutritional standards and a duced without difficulty. more positive state of nutritional health.Among Other nutritional diseases include the deficiency the many difficulties in reaching this object in some group of which beri -beri is one of the most important. parts of the world is the widespread prevalence of It is well known that beri -beri usually occurs among several deficiency diseases, of which kwashiorkor, or those who consume a diet composed mainly of highly protein deficiency, is the most serious from the public milled rice, and it is rare in those whose diet is based health point of view. on any other cereal. The first complete clinical account of this disease Endemic goitre is another deficiency disease which was given in Ghana, but the prevalence in the world bears much responsibility for poor social and economic isnot known.The conditionisassociated with conditions as well as forill- health.It has been insufficientproteinintake,especially around the estimated that there are some five million persons period of weaning.The majority of sufferers are suffering from goitre in India alone.Although it is between 9 and 36 months old.It seems that this may generally admitted that endemic goitre can be pre- be a total protein deficiency or a lack of balance of vented by the administration of appropriate amounts the amino- acids. of iodine, the practical difficulties that the less de- The prevention of the disease involves fundamental veloped areas have to face are serious.Considerable changes in the way of life of the people and requires advances have recently been made in the technique of co- operative efforts on the part of health, agricultural, treating crude salt with iodates, and programmes of fisheries, economic, and education departments. A prevention are now going ahead in Latin America great deal of research of both the laboratory and the and in India and some other countries of Asia. field type is going on, and most of it is devoted to Anaemia constitutes a public health problem of discovering ways of feeding children and providing great magnitude, particularly in the under -developed sufficient protein without using the costly foods such andtropicalareasoftheworld.Malnutrition as milk, eggs, etc. A great deal of progress has been underlies most of these anaemias, which affect parti- made in this extensive research, and there are now cularly certain vulnerable groups in the population some protein -rich vegetable foods on trial.Special -i.e., expectant and lactating mothers, infants and work has been done in Uganda, Coonoor (India) and young children.The high rates of maternal mortality Guatemala, and recently in other centres of investiga- in some countries are unquestionably influenced by tion. the prevalence of anaemia.Sinceitis usually a The technical approach towards the prevention and chroniccondition,anaemiaimpairshealthand alleviation of protein deficiency and other forms of working capacity and hence leads to economic loss. THE STATE OF THE PUBLIC HEALTH 25
These brief illustrations give some indication that of prevention. A special feature of recent years has a great deal of positive work is being done throughout been the development of health education in the the world on nutritional problems.Extensive research nutritional field, especially by securing the co- opera- is being undertaken into the causes of actual nutri- tion of the people themselvesatthe community tional diseases and also into simple and cheap methods level. CHAPTER 3
ADMINISTRATION OF HEALTH SERVICES AND ACTIVITIES
1. THE ROLE OF VARIOUS GOVERNMENT as there is no lack of continuity in the mental and DEPARTMENTS physical care of the child between infancy and school age. In this section we are not considering specific health A second feature of common interest to the two administration but the participation of other govern- departments is physical education and especially its ment departments in the many and varied activities mental counterpart in the promotion of the team which go to make a national health programme at the spirit in organized games and in all forms of outdoor administrative level.It is noteworthy that in recent recreation. years a substantial number of governments have given The third feature, and in many countries the central practical recognition to an integrating tendency by one of the educational system, is to achieve the greatest amalgamating certain central departments, such as possible degree of literacy.This might seem at health and welfare, health and social security, or even firstsight a commonplace with very littledirect health, education, and welfare.On the other hand, connexion with health.It must be admitted never- some nations have shown a trend towards further theless that the literacy of a people is a positive differentiation of departments, perhaps mainly on influence on health even at the simplest level of being account of the unwieldiness of the large central able to read and write. A person who can read is at administrative units for some functions which have least open to health education. been greatly expanded.An illustration of this is the The main object of compulsory education is to separation of personal from environmental health ensure that children grow up with enough learning to service, the latter including housing and town plan- carry on the ordinary affairs of life and to exercise ning.This may be a necessary consequence of a very their duties as citizens.Primary education is enough great post -war expansion of housing activities both to meet the minimum requirements, and it is essential for slum clearance and for new building to relieve that health education should be introduced at this overcrowding.In practically every country, however, stage, because an understanding of health needs and there exists at the governmental level a group of activities is part of the equipment of every citizen. departments with common interests in the broad field Children who reach the stage of receiving secondary of health, and, at the least, an arrangement for cross - education ought to have a much more elaborate representation by officials.The departments most concept of health, derived partly from specific teaching, commonly concerned with health in this broad sense but mainly from practical instruction through games are education, food, housing and town planning, and other outdoor activities and from more general social welfare and social security, labour, and trans- teaching in such subjects as geography, nutrition, and port. the art of living together.At the higher levels of education, especially in the training of teachers and other professional workers, health instruction should Education and health be regarded as one of the required subjects.Every In the practical issues the most important relation- effort should be made to instruct students so that ship between an education department and a health they may become teachers in health. department at governmental level is the school health At the present time one of the most urgent features service.The actual organization varies, as in some of participation by the education department is to countries school health work is under the direct introduce in each area an appropriate syllabus for supervision of the education department, while in education in health.It is clear that a syllabus of this others it is regarded as part of the functions of the kind cannot effectively be undertaken unless the ministry of health.It does not matter very much school- teachers are trained in the subject themselves. which administrative arrangement is made so long Many of those who are concerned with teachers' - 26 - ADMINISTRATION OF HEALTH SERVICES AND ACTIVITIES 27 training hold a strong belief that health education provides employment; and,third,this movement ought to be a general subject in the course of training, stimulates the building of houses.Unfortunately, and not primarily a special subject for the few.This when the industrial development itself is ill- contrived does not, of course, exclude training in health educa- the housing is planned in such an atmosphere of tion as a special subject for those who wish to practise haste that no proper consideration is given to the it as such -indeed specialists in health education are health aspects.In the more developed countries greatly needed.The advantage of general training today -especially when industrialization has taken in addition means that all who take part in the teaching place long ago, as in Western Europe -, the immediate profession are aware of the health aspect of education problem is usually one of creating an industry capable (see Chapter 4, section 5, page 45). of building more adequate houses for the lower income groups.The damage so far as slums are concerned has already been done, and all too often Housing and town planning the construction of new low -cost buildings has the In a large number of countries the establishment of double effect of raising the price of materials and a special department to deal with housing and town labour and, at the same time, of increasing the density and country planning isan innovation.Thisis beyond a maximum compatible with health.In partly due to the fact that, where economic develop- countries which are less developed, many houses are ment has taken place recently, the problem has only built locally and often by the occupants themselves. just come to the fore.As often as not the homes of The need here is slightly different because it depends the people in under -developed areas are of very light more on local training in the trade and on skilled use construction and everyday troubles of urbanization of local materials.It should be observed that over- do not occur.Design and lay -out cause little difficulty crowded conditions are not necessarily confined to when there are no water supplies or drains to be cities.Unfortunately, they can also be created, to an considered or when traffic is negligible.The returns extent detrimental to health, by the mere agglo- from various countries, including those in which meration of a number of ill- designed and badly built there has, as yet, been very little movement from rural villages. areas to the towns, show that there is one outstanding We are not concerned in this chapter with housing hazard to health -the overcrowding of families in and town planning except in relation to the role of their homes, however simple the structure may be. government departments in the protection and promo- From a very few territories comes the reply that they tion of health.As we have seen, the two hazards have no housing problem exceptovercrowding. that stand out clearly are overcrowding and dilapida- Indeed, a typical answer runs like this :" We are not tion.We have seen too that overcrowding has two troubled by housing problems, for every man is his aspects -the effects within the dwelling unit and the own builder and all his materials with the exception general effects of an excessively high density area. of roofing iron and cement are abundant and cost Unfortunately, thereislittlediminution of these practically nothing . .. The only real housing pro- hazards, because of certain factors :(a) the rapid blems are overcrowding and insufficient ventilation ". increase in population, especially in countries which Housing problems are universal, but two aspects have not the means or the organization to provide are a special danger to health, viz, overcrowding and low -cost housing and properly planned towns and dilapidation -a personal factor and an environmental villages;(b)the rapid industrializationin many one.Overcrowding is liable to be found, even in the hitherto backward areas.This causes rapid migration most remote villages, where families are herded to- to the industrialized towns, most of which are entirely gether.It exists in an aggravated form in areas of high unable to meet the inflow in the sense of providing density where not only the individual householders reasonable accommodation.This situation gives rise but the entire community have to live in a crowded to the squatting of migrants in the older towns them- space.Through the years we see the overcrowding selves and their outskirts, and, in addition, around sequence constantly repeated from one territory to new factories.The role of the government depart- another.It is doubly injurious to health when it is ments is admittedly a very difficult one, but in broad accompanied by slum building and a total neglect of terms it means, first, a central planning of areas in planning.The steps in the sequence are generally which low -cost housing can be provided; second, the these :first,a more or less rapid development of economic planning of the building industry in such a industry takes place in a district; second, in conse- way as to develop a coherent housing scheme; third, quence of this there is a rapidly growing movement of the insistence, by legislation, on a reasonable water people from the country to the towns, where industry supply and the disposal of waste; and, fourth, a close 28 FIRST REPORT ON THE WORLD HEALTH SITUATION link with the ministry or department of health at the the hazards of life- sickness, unemployment, widow- centre in order to provide for inspection, education, hood, and old age.The provision for war pensions and, in the last resort, control of the crowded areas. has also been included in the sphere of a ministry of Housing and town planning offer almost insuper- social welfare.Most of the social security schemes able difficulties in areas undergoing urbanization.In depend on contributory insurance, a system that is addition to the government control referred to above, feasible when there is full employment and stability the devolution of powers upon local authorities who in the social structure.It can be applied only imper- are in daily touch with the problems is essential. fectly and with great difficulty to ill -paid, irregularly Indeed the role of the central department in relation employed workers of the casual type.Such workers, to health is one of general planning and of setting up including domestic servants and self -employed artisans model schemes of lay -out and construction; but the and traders, are not usually covered by social insurance actual conduct of housing and town planning must be schemes, or even by legislation for the protection of undertaken at the regional or local level in close co- health and safety.In Mexico, for example, in 1954, operation with health departments. the total number of persons entitled to social security The main objects of a town and country planning benefits (medical services, and sickness, invalidity, scheme are:first,to secure a lay -out of houses, and maternity payments) was less than one million industries, shops, and public services that will create out of a national population of about 30 millionIt a properly balanced community; second, to provide is thus evident that the major risk to health in social all necessary services -e.g., hospitals, clinics, health security systems is that of " feeding the fat with the units -, to maintain health and to care for the sick; cream and the lean with the skimmed milk ".In third, to provide environmental services sufficient in other words, those who stand nearest to the margin scope and extent to assure the conditions necessary of poverty and ill- health are the least likely to benefit for a healthy community (this includes an adequate from such provisions.For this reason alone -and and safe water supply, piped to individual premises, there are many others -it is essential that the depart- and a proper system for the disposal of wastes, includ- ment dealing with social assistance should work in ing drainage and sewage disposal); fourth, to supply close touch with the ministry of health, to ensure adequate lighting, heating and ventilation to individual that health services and some form of relief from premises; fifth, to avoid the risk of air pollution by poverty and suffering are available for those who do industrial plants and domestic heating arrangements; notqualifyforofficialinsuranceschemes.The sixth, to provide sufficient open spaces, both around existence of a plan for social security is not in itself a the area and close to the dwellings, for the healthy sufficient guarantee of the health and well -being of recreation of both adults and children; and, seventh, the people.The real test is the proportion of families to do everything possible to prevent injury to natural covered by the various schemes. beauty. Housing problems, as opposed to town planning schemes, are more concerned with the details of Work and health construction and lay -out.The primary difficulty is In the central government of the various countries most frequently the clearance of existing unfit houses and territories there are many different patterns of and the relief of overcrowding. labouradministration.Takenatrandom,these include labour and welfare, labour and national Social welfare and social security insurance, labour and national service, and so on. The relationship with the health service also varies, Government departments devoting their services to but the principal association is in connexion with the social security are of comparatively recent growth. supervision of working conditions, the prevention of Insurance itself, on a national scale, goes back only industrial hazards and diseases, and the organization to the German experiment towards the end of the of an industrial health service.In some countries all 19th century, and the British system of national these functionsaredirectlyadministered by the insurance dates from the year1911.Of recent ministry of labour, while in others the more strictly years, however, a number of governments- notably medical duties are the responsibility of the health in South America -have started a bold experiment by department, leaving the technical inspection to the setting up a special department for social security. department of labour.There are arguments on both In the more lately developed countries the trend has sides: on the one hand it is stated that a country's been towards centralization of social welfare services, health service should be a unity, and that the worker particularly the great schemes for insurance against is the same person whether he is at home or in the ADMINISTRATION OF HEALTH SERVICES AND ACTIVITIES 29
factory; on the other, it is pointed out that much of for many years and, with increasing transport, the the health work in industry is highly technical and variety and incompatibility of such regulations have closely related to problems which are in their essence led to difficulty and delay.It is only in recent times industrial.In a number of countries a satisfactory that order has been achieved out of a chaos of national division of functions has been reached, as, for example, restrictions.Nevertheless,the regulations of one in the Netherlands, where the central authority is the country and another, although in many ways effective Ministry of Social Affairs and Health, and in Norway, in keeping out such diseases as plague, were useful where there is a recognized division between the reminders to governments of the dangers of com- Ministry of Local Government and Labour on the municable disease and of the need to establish some one hand, and the Ministry of Social Affairs on the organization to check dissemination.As early as 1725 other.The situation has been summed up by one the threat of plague in England led to a short -lived expert as follows : governmental measure, but it was not until the last " Sooner or later a fusion between the [National Health and quarter of the 18th century that the governmental the Industrial Health] services seems likely and it is hoped aspects of public health received orderly attention that this will not be delayed over long.At present in the from the authorities. National Health Service [of the United Kingdom] the emphasis is on treatment.There is certainly need for a more preventive Public health services proper -as a government outlook and this should not omit special problems peculiar to organization -belonged to the 19th century and were working groups.These are by no means limited to the provision made necessary and urgent by the great development of an innocuous physical environment such as would be pro- in industrialization which took place in Western vided by the perfect application of the Factories Act.The Europe, especially in Great Britain. health of the individual may be profoundly affected by the work he is doing and the group in which he works, and any In earlier days, as has been indicated, transport by service which omits consideration of these factors is incomplete. sea was the most usual method for the transmission There should, moreover, be the closest link between the services of diseases such as plague, cholera and smallpox. providing treatment and after -care, and those dealing with the In the long journeys from East to West, however, it medical problems of industry.At present this is provided only where there is a voluntary health service.There should be was highly probable that any disease contracted channels of communication between the public health services before embarkation would be manifest before the ship and the small working units which at present have no medical sailed into port.Quarantine regulations thus had service. " 1 considerable practical value in enabling the sick to be taken to hospital, the ship disinfected, so far as was necessary, and the contact passengers either isolated Transport and health or kept under strict observation by the appropriate The measures taken by peoples to protect them- health department.All this has been changed by the selves from the introduction of disease from without invention of the aeroplane.The speed of transport extend far back into antiquity.Among the most by air has now made it certain that many of the com- elaborate codes of this kind in the written history of municable diseases will not appear until long after man are the regulations set out in the Hebrew scrip- the arrival of passengers from a foreign country, and tures, chiefly in the Book of Leviticus.Restrictions therefore the old quarantine has had to be modified of this sort were especially important where disease by the new circumstances.Most countries are now was carried from country to country by shipping. handling both local and international air services and Indeed it may be said that quarantine was the founda- thus the need for protective measures has become tion of public health in a restrictive sense.Actually virtually universal. in the United States of America it went further than that, because an Act of Congress of the year 1796 placed quarantine under the Secretary of the Treasury, 2.THE ROLE AND STRUCTURE and in this way the marine public health service was OF HEALTH ADMINISTRATIONS initiated.Out of this service grew the United States The national level Public Health Service. In European countries and in many maritime cities The development of national health administrations elsewhere quarantine regulations have been in force has, on the whole, followed a similar broad pattern since the end of the First World War.The concept 1 LANE, R. E. (1956) Occupational health and the National of national guidance in health matters has spread far, Health Service in Great Britain.In: World Health Organiza- even in countries -such as those of Western Europe-. tion, Regional. Office for Europe, Information on occupational health and related legislation in the European region (unpublished which had hitherto depended on local government mimeographed document MH /EUR /48.56), Geneva, p. 70 alone or in combination with voluntary bodies, fo 30 FIRST REPORT ON THE WORLD HEALTH SITUATION their public health services.This has not necessarily recent experience has shown that there are certain amounted to centralization, except in certain coun- functions which ought to be preserved and strength- tries, but it has involved as a rule a supervisory ened at the national level.The first of these is service, both financial and technical, aimed at securing international activities.Public health practice cannot greater uniformity of action and co- ordination of be confined within national boundaries, and what is major services such as water supplies, the control of happening across a frontier or even over the sea is of communicable disease, and the supervision of town immediate interest to any country.One of the prime and country planning.In countries where there is a measures to be taken is to secure a good system of federal government, the states or provinces usually intercommunication to ensure immediate notification have executive powers and are to that extent decen- of the occurrence of epidemics or of other disastrous tralized.Even under theseconditions,however, events.Another important feature of international there has been a trend towards the exercise of greater work is exchange of experience and collaboration in control from the centre by means of financial grants services which require collective action. to promote certain medical services, and especially An additional function of a national administration in the form of overriding powers in the event of is to plan nation -wide, long -term programmes, includ- widespread epidemics.Sometimes,asin housing ing the co- ordination of all types of health services in and town planning schemes, there are concurrent the country by maintaining common working arrange- powers, exercised by federal and state or regional ments with other government departments engaged authorities, or by a central government and its local in any branch of health activity, such as education and authorities. trainingof medical and para- medicalpersonnel, After the end of the Second World War health occupational health, medical care, food and nutrition, administrations at the national level developed rapidly, and social security.As regards the entire area of as political leaders became more conscious of the operation, national administrations in many countries importance of social and economic development and have also taken an important part in the continuing of health as an essential element in that development. study of the health needs of the people, with the object National health authorities in many countries have of giving guidance and financial and technical aid to prepared nation -wide schemes for campaigns against the local services.This role is becoming increasingly the major epidemic diseases and provided basic important, in the form of providing advisory services medical services in remote areas where the population and technical assistance through the agency of spe- has been deprived of such facilities.Each of the cialists in various branches: public health administra- 157 countries or territories reviewed in this report has tion, epidemiology, nursing, health education, school some kind of central health administration, and 76 of health, nutrition, maternal and child care, public them have established a ministry of health or its health laboratories, and sanitary engineering.In equivalent at the centre.Many of these departments addition to these technical functions it is also part of have an elaborate organization for both general the duty of the central department to advise the govern- administration and technical direction and supervision. ment on the provision of financial aid (grants -in -aid) Under general administration the usual divisions of to the state or local health administrations, taking health activities, together with routine administrative into consideration the balance of needs and resources and financial units, are represented, including, in a between urban and rural areas.In most countries it number of countries, a division of international also has the duty to prescribe and maintain standards health.In the technical field institutions are being in a great variety of conditions, extending from pro- set up for research and field investigation, directly fessional training to the protection of the public in under the central administration.Such institutions relation to foods and drugs, housing and environ- -the national institute of health, the national academy mental conditions, and measures of public safety. of medical sciences, public health laboratories, serum and vaccine laboratories, and others -have proved valuable in raising the standard of public health The state, provincial or regional level practice.In a few countries a special commission At theintermediatelevelthesituationvaries has been established in the ministry of health for the greatly according to the powers delegated to the planning and co- ordinationof nation -wide pro- health authority.At one end of the scale is the state grammes. or province which undertakes all functions except a The role of a national administration is essentially small number reserved for a federal or supreme one of co- ordination and supervision, if both regional governmental authority.At theother endisa and local government is well developed.However, highlycentralizedtypeof nationalgovernment, ADMINISTRATION OF HEALTH SERVICES AND ACTIVITIES 31 generally in a small country, with no intermediate The local level organization atall but with local authorities more or less directly under the executive control of the At the local level the emphasis lies on executive national government.Between these extremes there work.Larger local authorities, in town and country, are different forms of regionalization, varying accord- carry out in detail such schemes as have received ing to geographical and political circumstances.The higherapprovalinpersonal and environmental Commonwealth of Australia is perhaps characteristic services.As we approach the smallest health unit, of one extreme, because of the geographical difficulties, the tendency is to link more and more closely the which have in fact been successfully overcome by the treatment, the preventive services, and the promotion arrangements adopted.In this case each state govern- of health.The essential features of the work carried ment has a minister responsible for the health services, out at a local health centre or unit are medical care, a chief medical officer and a full range of staff dealing communicablediseasecontrol,healtheducation, with all problems of medical care, the prevention of environmental sanitation, maternal and child health disease and the promotion of health; within the scope including ante- and post -natal care of the mother, the of the powers delegated to it, each of these states care of the pre- school child, and, in co- operation could be regarded as a national government in itself, with the education authority, the whole range of and for health services it is divided into local authori- medical provision for the child of school age.The tieswith limited executive powers.Towards the care of the aged and the chronically ill and rehabilita- other extreme, one might take the country of Israel tion of the disabled are sometimes also the functions as an example, with its concentrated population and of the local authorities. no intermediate level of health administration.Cer- In a number of countries the local authority, tain large countries also tend to concentrate the particularly in urban areas, also makes arrangements executive power in the central government.But the for the examination and preliminary care of adoles- trend isto delegate normal services to the local cents when they are leaving school and going into health authorties, which have considerable powers industry; but a special service is necessary for their to act, so long as they conform to the main pattern placement and medical care in industry. designed by the central administration. In the control of communicable disease the local From the technical point of view the intermediate health department has a role of capital importance. authorities, whether provincial or regional, generally A health officer at the local level is not concerned with find they can work more effectively in conjunction the precise clinical and laboratory study of the indivi- with local authorities.Their function is to provide dual patient nor primarily with the broad epidemiolo- specialist services in medicine and public health in gical aspects of the outbreak of a communicable order to assist the local services to raise their standard disease.He is concerned, however, with the imme- of work, as well as to solve some of the problems diate protection of the people whom he serves by which are beyond their capacity.Regional hospitals, isolation of the sick and by taking all precautions public healthlaboratories,regionalsanitary and against the spread of the disease. epidemiological stations, control of river pollution, The promotion of health by educational means is regional planning, water supply and sewage -disposal primarily a function of the local department.Assist- schemes are some of the examples of the specialist ance may be obtained in the preparation of more services existing in a number of countries.As useful expensive methods of demonstration by film and additions to the general structures of state or provincial television, but it is of the greatest importance that administrations, regional health demonstration and health education should be directed first to local training centres, medical supply depots, serum and problems which the people in the area actually see and vaccine manufacturing laboratories, etc., have also understand.This is especially true when there are been established. wide variations of custom and tradition between one In general, the two essential functions of an inter- area and another under the same national govern- mediate health authority are the organization of any ment. system which naturally goes beyond local boundaries, In many countries local health units have been such as (a) general and special hospital services and established, particularly in rural areas, to provide specialized laboratory or investigation work, and both curative and preventive services, with doctors, (b) the planning of services which require the co- nurses, midwives, sanitary inspectors and auxiliaries operation of more than one local authority, such working as a team. A local unit is not limited to the as control of river basins or town and country work of the local health officer and his full -time staff. planning. To an increasing extent it is a centre for the work of 32 FIRST REPORT ON THE WORLD HEALTH SITUATION the general practitioners of the area and of nurses a real risk of hospitals becoming swamped with long- dealing on a day -to -day basis with patients.It is term cases. here that medical treatment and health promotion There was, however, a growing realization that it should be united by the health officer working in close was not enough simply to set up health units in little co- operation with the family doctor and the popula- towns and villages and leave it at that; the essential tion.It is here, too, that the actual organization of element was tosecure and maintain community field studies and trials finds its focus.In all field participation.As Winslow pointed out, health is research it is essential that the general practitioner not something which can be imposed by a fiat from should feel himself part of and partner in a team and on high. not just a scribe sending reports to a remote authority. " Its attainment depends on the interest and willingness of His best work is done when he can discuss his every- individuals and groups to assume responsibility for the solution day problems with other members of a health team of their own problems on a well- informed basis.People are more prone to apply acceptable health practices in their daily whom he can see personally. lives if they have had a part in determining the changes desired In addition to this, it has been shown in many areas in partnership with the professional health workers. " that there is a widespread movement towards the extension of home care under the general practitioner, This valuable concept has been steadily accepted especially forthe aged and the chronically sick. and is being extended to cover the wider area of This is the reversal of tendency which had been community participation, not in health alone, but operating between the two World Wars -a kind of also in such activities as agriculture and home econo- pressure (possibly related to the difficulties of housing mics, nutrition services, education, social welfare, and and domestic service) to admit the elderly and the other programmes which can readily be integrated at chronically ill to hospitals in preference to treating thelocallevel.Community development inthis them at home.The result was that institutions were sense requires a small, coherent body of people with being used to an increasing degree for this group of many common interests. cases, and hospital beds, especially in the small and more general units, were becoming occupied largely WINStow, C. -E. A. (1951) The cost of sickness and the by patients who were likely to remain for an indefinite price of health (Wld Hlth Org. Monogr. Ser., No. 7), Geneva, period.Since the Second World War there has been p. 57 CHAPTER 4
THE DISTRIBUTION OF FUNCTIONS IN THE HEALTH SERVICES
1. MEDICAL CARE, INCLUDING HOSPITAL, infectious diseases on the one hand and the increase CLINIC, REHABILITATION AND HOME SERVICES in the speed, hurry and anxiety of modern life on the other, accidents have acquired an unenviable promin- Hospitals ence as a cause of disability in the industrialized The organization of medical care among the nations countries.Recent statistics prepared in the Nether- of the world has followed several different patterns. lands and a number of other populous and industrially Some of these are the legacies of old tradition, and developed countries indicate that accidental injuries others are related to the degree of social and industrial at home and on the road are creeping up to the first development.In a number of countries, for example, place in the records of morbidity, especially among the hospital has won a unique place in the loyalty and children.Industrial injuries, and the long train of affection of the people, while in others it has been incapacities following war, are prominent causes of looked on as a temporary unit run up hastily to meet anxiety in many countries.There are, in addition, the threat of some pestilence and discarded when the a number of diseases which have recently become immediate danger is over.In many of the highly menacing even in remote areas; the most serious of industrialized communities today the local hospital these from the point of view of disability is poliomyel- is constructed and tended with lavish care, and its itis, which is leaving its trail of cripples all over the design and capacity, its up -to -date equipment and world.There is one more cheerful aspect, however, services, are objects of pride to the community.It in the discovery that a large number of people afflicted is hardly doubted, in all these varied circumstances, by paralytic disorders resulting from such accidents that the purpose of the hospital is to heal the sick, or as cerebral haemorrhage and thrombosis, or from at least to provide the highest possible quality of chronic degenerative conditions of various origins, therapeutic care.Where the ravages of thefar - can be greatly helped towards functional recovery by reaching communicable diseases are barely held in modern methods of medical care. check, it is natural that the urgent cure of the sick The above considerations bring us to the second should occupy the minds of government.Neverthe- function of the hospital as we see it today: the restora- less, the introduction of large -scale methods of pro- tion of the disabled to the fullest possible mental and tection against the widespread scourges like malaria physicalactivity.Thisprocessofrehabilitation has begun to alter the more conservative attitudes. constitutes an important advance in medical care. The treatment of the sick still assumes the first place The complete process involves a co- ordination of in medical care, but the success of campaigns against services if the best results are to be achieved.In the malaria, yaws, leprosy, and tuberculosis has begun medical world of tomorrow rehabilitation will be to catch the imagination of those responsible for the one of the great contributions of the hospital to health of their people. health.But governmental returns of today show These advances, important though they are, do not that the real difficulties lie, not in accepting the idea carry us far enough into the realm of preventive of restoration, but in the shortage of trained per- medicine.The question that arises in many countries, sonnel.In general it may be said that training could in both urban and rural communities, is the proper well be carried out in most of the countries themselves. place of the hospital in a comprehensive public health Reference has already been made to the chronic programme.It is in the first instance dedicated to degenerative diseases; and the hospital has an impor- the treatment of the sick, but its functions in the tant part to play in prevention as well as rehabilitation. restoration of sick and injured persons to the fullest This group includes the long -term rheumatic diseases, possible mental and physical capacity have not yet cardiovascular disorders, and the neoplastic condi- been very widely realized.It is to be observed that, tions.It is for the time being a somewhat sinister with the decline in the seriousness of the commoner reflection that the proportion of chronic degenerative - 33 - 34 FIRST REPORT ON THE WORLD HEALTH SITUATION diseases in a community is a positive measure of the administration -in that order of importance.The state of its health, for these conditions affect mainly hospital should at the same time be capable of rapid the older age -groups, which are only slightly repre- adjustment to emergency needs, and of adaptation sented in the less advanced peoples.On the other and, if necessary, of enlargement to meet the changing hand some of the long -term infections diseases such requirements of medical progress.It is not far from as tuberculosis and rheumatic fever do their worst at the truth to say that the worst kind of hospital is the the younger ages.Reports from island peoples with one that is likely to outlast a generation; in the hardly any industry suggest uneasiness about the planning work of today one of the outstanding spread of both these diseases, especially in recently difficulties has been the reorganization of outdated developed townships.In the countries where environ- hospital buildings.In a number of the returns from mental conditions have been brought up to a high individual countries one notes now and then with standard, especially as regards water supply, waste relief a statement that the old hospital is being demol- disposal, housing and the relief of overcrowding, the ished and replaced by a building of simpler construction worst features of rheumatic fever and tuberculosis which will have much greater adaptability. are disappearing. The second element is in a sense the opposite of Carcinoma, another disease of the later age -groups, the first : it concerns the need for making the adminis- has been giving rise to increasing concern in the more trativeandresidentialaccommodationrelatively fully industrialized countries.Cancer is a disease permanent.The patients come and go, and their in which early detection and skilled treatment may needs are met by the provision of comfort with, of save life, and in this way it is part of the hospital's course, all the skill that great professions can supply. function to secure regular clinical examination as a The staff, on the other hand, are relatively permanent, routine, particularly at the middle years of life. and it is desirable to provide for them all the require- An important group of chronic diseases is associated ments for healthy recreation and for the pursuit of especially with industrial hazards.The most serious personal interests and hobbies.The administrative of theseispneumoconiosis.Some of the more offices also require a greater degree of solidity and recently industrialized countries have not yet reached permanence than the wards and the technical services. the stage of taking the full precautions for the protec- On the whole, hospital plans seem to pay too much tion of the worker against this disease, or for his attentiontotheheavy construction of patients' continued care when it has made its appearance. accommodation and to the housing of apparatus It is clear, however, from the replies of governments which may be obsolete in a short time or require that an increasing number of countries are becoming extensive additions and modifications, and to give aware of these risks and are taking legislative action too little care to the needs of the more permanent to secure a high degree of safety under working residents, medical, nursing, and auxiliary. conditions. These considerations lead us to the question of There are two further elements in hospital care providing for the training of personnel in the larger which have long -term effects for better or for worse. institutions.Itis impossible to establish a sound The firstof theseisintelligent hospital planning pattern of hospitals and clinics in a country or region, according to the needs which a hospital will have to unless staff of all kinds are properly trained both in meet within its own community.In many of the the practice of their own skills and in working as a economically advanced countries in the past, and in team.Hospital administration itself is a profession some of the rapidly developing areas in post -war of increasing importance asthe system expands years, there has been a tendency to insist on the throughout so many countries.Hitherto, the train- construction of elaborate buildings forrelatively ing schools in the United States of America have been simple purposes, with the result that money is spent all but alone in this work, but in recent years schools unnecessarily on structural work which ought to of hospital administration have been created in change and expand year by year with the advance in widely spread cities of the world. scientific technique and discovery.It is true that In the training of medical, nursing, and other pro- in areas of high density where land is at a premium fessional staff it is encouraging to observe from the it is necessary to build a costly, many- storeyed struc- replies from the more scattered areas that there is a ture; but this should be regarded as a stern necessity constantly increasing degree of co- operation between and not as a virtue of planning.The secret is to territories, to avoid the expense of overlapping and design the simplest unit that will function well for at the same time to ensure the provision, at a central the comfort of the patients, the work of the medical training school, of a high quality of teaching staff. and nursing staff, and the general requirements of A steady improvement in curricula is also noticed, THE DISTRIBUTION OF FUNCTIONS IN THE HEALTH SERVICES 35
with full -length courses for the professional groups. Clinics and home services This has the additional advantage that the men and Many countries report that, while their proposals women who have been trained at these centres are in for new hospitals have been subject to financial a position to return and take part in relatively simpler restrictions, they have been able to go forward boldly courses of teaching for assistants, in districts where with the creation of a chain of out -patient clinics it would be impossible to achieve a full quota of linked with a general hospital.In the more populous qualified staff. townships these clinics are of solid design and fulfil Up to this point we have been discussing the hos- the object of providing a meeting -place for the general pital as a single institution; but in a growing number practitioner, the health officer and the " visiting " of areas this concept of the hospital is being steadily specialist.They also undertake strictly preventive enlarged to cover an area or region.In this setting work through maternal and child health clinics, as Its the hospital is no longer a unit but a service. well as arrangements for health education.There influence spreads through the area in the form of has not as yet been any remarkable extension of out -patient clinics, often with a few beds in the mental health and child guidance clinics, but the remoter and lessaccessibledistricts,and health foundations are at least laid, ready for building upon centres in towns and villages.In addition, many when time, staff, and circumstances permit.In some countries are developing regional schemes by means of the more difficult areas great use has been made of of which all the hospitals and other medical care travelling clinics, and these have been organized by services are joined together to render a two -way road, river, sea, and air.In islanded areas the sea- service to the community.That is to say, the central going vessel has again and again proved its value as a hospital receives from all over the region patients clinic, and its staff are usually on call by radio. sufferingfrom complaintswhichrequirehighly In some tropical countries and in scattered villages specialized diagnosis or treatment and is prepared to elsewhere a more stable project is the rural health send out specialists to the local hospitals and health unit.This unit, which generally serves a group of centres for consultation.The peripheral areas, for villages, is at its best a fine example of team -work. their part, help to keep the general practitioner in Its full staff consists of a general practitioner, a group touch with the centre, and at the same time they are of public health nurses and their assistants, together the best units for the creation of a combined service with engineers and sanitarians, and the necessary of treatment,prevention, and the promotion of auxiliary personnel. A unit of this kind not infre- health.The rural centre should be a pillar of a quently becomes the focus for a group of smaller hospital system.Both centre and rural clinic have " health stations ", each in charge of a public health equal parts to play in the service, but the former nurse, and visited as a matter of routine or according concentrates its attention on the skills of diagnosis to need by the clinic physician.During these visits and treatment of the individual, while the latter is prevention, health promotion, and treatment can be primarily devoted to the prevention of disease and combined without difficulty. the promotion of health, both in the individual and The last bulwark of defence against sickness is in the group. home care under the family doctor.This is especially The hospital serves an important public health applicable in chronic illness and in the medical care function in the maintenance of accurate records. of the aged and infirm.There are, however, certain These medical records are the nucleus of sound important limitations to the acceptance of home care research and field epidemiology, and they should as a substitute for hospital.These will be considered serve as a basis for extended trials and studies by later (see Chapter 5, section 4, page 76). general practitioners in the course of their practice and in their work at health centres. Hospital records are also most valuable indicators 2. MATERNAL AND CHILD HEALTH of the end -results of hospital treatment -surgical and medical -through follow -up in the out -patient depart- It is evident from the replies of various governments ment. A surgeon (let us say) has performed a series that the activities of maternal and child health services of operations, using a new technique.Was this have won widespread acceptance and understanding. method justified by the immediate and the long -term The idea of their function in raising the standard of results ?The records of the hospitals and the sub- health and well -being of mothers and children has sequent investigations in the homes of the people are now passed out of the range of controversy. evidence of the first order.So it is with a new drug or The maternal and child health movement is a a new form of treatment introduced by the physician. leading example of community effort, and in many 36 FIRST REPORT ON THE WORLD HEALTH SITUATION
areas it was in fact the first community health service. municable disease; and on the other hand the strategy The essence of community development lies in its against infection smoothes the way for work with success in creating a team -spirit between the agencies mothers and infants.Without doubt a considerable for health, education, and general welfare at the part of these efforts is limited in scope and in quality, local level.It thus offers unusual scope for voluntary but each advance encourages further efforts.In the work, but without overlapping or dissipation of Eastern Mediterranean a shortage of midwives is effort.This is the key to progress. reported, but the traditional birth attendant is being The obstacles impeding the integration of the replaced by trained staff and by hospital facilities. maternal and child health movement with other health A combined rural health programme for creating one services have been considerable, but today there are centre for a population of 15 000, with smaller auxili- strong reasons for believing that they are gradually ary units, has been accepted as an aim in one highly being overcome.One of the initial difficulties was populousruraldistrictof Egypt.In European that in certain countries the MCH movement was countries there has been striking progress in the first in the field and well established at a time when a establishment of rural MCH services, in many cases publichealthprogrammebarelyexisted.When as part of an existing health centre system.Training this situation occurs, the MCH services are operating facilities are of first importance, to ensure sufficient against great odds: the lessons which their staff try staffing as plans are realized.Such facilities include to drive home gain no support from the local environ- refresher courses in some areas for both doctors and ment as regards either sanitation or the elements of nurses.Schemes for the care of premature infants personal health care. have also received attention.In Asian countries In many countries it is clear that progress is being progress has been uneven but encouraging on the made towards integration.The secret of further whole.There has certainly been considerable expan- development lies in union with the general health sion in quantity owing to serious want of coverage ; programme ; and in this advance voluntary associa- but in some countries attention has now been turned tions have played a full part.It is essential that their to quality. A great deal depends on the recruitment interest and active support should continue to be and training of supervising staff and on well- designed encouraged, and useful ways of doing this have been demonstrations.Thereisa growing appreciation adopted.The first was to arrange joint meetings of the need for training in order to replace the tradi- between voluntary agencies and local health officers tional birth attendant as time goes on.In all areas and so to inspire them with the idea of team -work. an outstanding advance is being made by linking The second method was to bring into harmony at the MCH with other health activities, ideally under the community level all the services which touched upon same roof. health and welfare and which could be lifted up by In the Western Pacific region one sees the gradual self -help.And thethird procedure involved the advance from the urgency of providing MCH services creationof a communityorganization,capable in hospitals to the setting -up of simple health centres withinits own limits, which servestostimulate to meet the needs of the more remote areas.This is governmental authorities to offer further assistance part of the general movement from treatment towards by means of suitable grants and by expert guidance prevention, although the liaison with hospitals with and friendly supervision.In some areas the com- a view to securing skilled medical care must be main- munity plan has had to lay its major emphasis for the tained.Midwifery services have also been extended time being on a special campaign against malaria, or in the Latin American countries and efforts have on an agricultural project, and the function of the been made to provide some training for the traditional rural health unit is to make sure that each field birth attendants.There is also a trend in the direction activity has its proper place in the common purpose, of incorporating MCH work in the general health and that it makes its contribution in an orderly way. service at the village or rural level. In the local services the needs vary a good deal. In the more populous districts, especially in urban In someareas -Africa,forexample -the MCH and fringe areas, many of the difficulties that arise programme is co- ordinated with the control of com- are due to housing shortage and lack of planning. municable disease.This isnot just a matter of Governments are so overwhelmed with a flood of administrative convenience; on the contrary, the parallel functions in health and housing that they combined effort is much more efficacious than the find it hard to provide the necessary financial assist- two separate endeavours.The MCH nurses and ance.When families crowd into the towns in search auxiliaries are thus able to get access to families and of new employment, or as the sad residue of political open the door to those who are investigating com- upheavals, their living conditions are usually worse THE DISTRIBUTION OF FUNCTIONS IN THE HEALTH SERVICES 37
than anything found in rural life.In such circum- country to country.In most Latin American coun- stances the hazards of infant life are much increased, tries and in large parts of Asia the administration is a and in early childhood there is earlier exposure to function of the ministry of health, but in parts of infectious disease and a greater chance of complica- Europe, the Eastern Mediterranean, and the Western tions.There is also a higher prevalence of under - Pacific, the departments of education are in charge. nutrition, partly on account of the wretched environ- The combination of the MCH service with the school ment and partly because of more widespread infesta- health service has much to be said for it, because of tions.One of the unfortunate features of these areas the need to secure continuity in the care of the growing is that the medical service fails as a rule to reach the child.It is a pity to make a partition at or around normal standards of the urban community, so that the age of admission to school.The essential thing mothers and children have the worst of both worlds. is that all aspects of child care be covered.It has The special problems of the so -called fringe areas, been observed, for example, that orphanages and whether arising from urban overcrowding or from other institutions for children have fallen into a no- fusion of rural populations, deserve urgent study.It man's -land between the two government departments; could be argued with force that the establishment of and sometimes day nurseries may owe a frail allegiance health centres of the rural unit type in these districts to one or other of the two departments, without there is quite as urgent as the village community develop- being any cohesion. ment. The period of childhood which lies between the As we move upwards in the scale of administration, second and the fifth year tends to be overlooked in there is a strong case for providing MCH advisers at most countries.Itis during this period that the theprovincialorregionallevel.At thatpoint attendance of mothers at infant welfare centres drops clinical, educational, and administrative advisers are off, and the work of the centres is not replaced, reasonably in touch with the areas served; and the because no service exists for the care of pre -school clinical staff especially are in a position to visit the children.This is especially unfortunate in tropical smaller units at regular intervals and to help to co- countries, as the pre -school period is a time of high ordinate the service within the region.This function sickness and death rates.These dangers are pre- is important in relation to maintaining staff during ventable.One of the best means of securing attention holiday and sickness periods, and it also helps in the and care is to increase the number of home visits arrangement of training courses, many of which are when there are " toddlers " in the home as well as undertakenatregionalheadquarters.Not infre- infants.It is important, too, that there should be a quently there is a good general hospital at the centre good service for the transport of the sick child to of a province or region, and MCH activities form a hospital, in order to ensure early care and, if necessary, valuable reinforcement of the preventive services as admission to the wards.One of the well -known a function of medical care. A further point is that troubles with this age -group is that the sick child the regional hospital is devoting more and more goes down rapidly unless he receives prompt, skilled attention to the early diagnosis and follow -up of attention.He responds badly to nutritional faults physical defects in children, with the object of ultimate and ishighly susceptibletothegastro -intestinal correction.At every level of medical care the conjunc- diseases.There is good reason to believe that the tion of prevention and treatment has become a matter greatest single advance in the medical services for of forward policy.Similar considerations apply to children is the appointment of nursing staff with a mental disorders; it is not possible in any but a few sound knowledge of nutrition and a capacity for areas to supply the services of mental health workers, dealing promptly with the common disorders of the either at the rural unit or as part of the activities of pre -school age. the community team.But the presence of a child In the school -age group considerable progress is guidance team at the regional headquarters raises new being made.This is a less difficult business than the possibilities for co- operation and for the promotion care of the pre- school child, because the school child of mental health. is, so to speak, much more accessible to the health In the national health administrations substantial worker.There are two main aims which have been progress has been made in the co- ordination of MCH increasingly recognized in the programme :the first and nursingauthorities,but the further linkage is to do everything possible to raise the health level with the general health services, by means of a co- of the children, and the second is to deal effectively ordination committee at the centre or through some and quickly with the child who shows an abnormality. other expedient, would be a step in advance.Res- In many countries in which the home environment is ponsibility for the school medical services varies from poor the school ought to set an example in healthy 38 FIRST REPORT ON THE WORLD HEALTH SITUATION living.This would imply good sanitary conditions capacity of the country.One good road to take is to in and around the school premises and a progressive use the first centre for short periods of instruction system of health education in which the children can for field workers and for the selection of suitable carry home lessons to their parents.In this respect candidates for training. A second stage, which has the child is the father of the man. The part taken been followed successfully in some countries, is to by the teacher is of the greatest moment, because he use the centre as a service station for mobile teams. is in contact with both parents and children and is in This has a double value : the teams are provided with a position to play a useful part in health education. a focal point for report on progress and interchange The main point is that the teacher should be really of experience, and staff and equipment can be checked interested in health work, as well as in maintaining and changed according to need.In addition, an the school and its surroundings as a friendly and opportunity is offered for the evaluation, by senior welcoming place. A school garden, made suitable for staff, of the work of the mobile units.It should be growing vegetables, has proved to be a useful method pointed out,however, that in the overwhelming of imprdving nutrition as well as a lesson of great majority of cases the mobile unit is intended to be a value in promoting a sense of responsibility.The temporary measure pending the setting -up of a per- existence of outdoor work and play helps the observant manent centre or sub -centre, with its own proper teacher to pick out the child who is hanging back, staff and equipment.In other words it is an advance physically or mentally, and may enable him to note post awaiting consolidation. the beginnings of sickness. To sum up: great stress should be laid on the Some of the questions which lie unanswered in the importance of securing the keen and understanding reports of the various countries are concerned with co- operation, on a voluntary basis, of the people on prioritiesinthe MCH service.When sufficient the spot.It is their goodwill and active help that will finances are difficult to secure, where can the best in the end determine the success or failure of a local start be made ?If a country is concerned mainly programme and the progress of community develop- with quality of service, then it may be argued that ment.As a project develops and expands,itis one part of the population is being favoured at the essential that it should incorporate plans for teaching expense of the other.On the other hand, if quantity at the local level -that is, for refresher courses to is favoured on the grounds of fairness to all, then the raise existing standards, and for the selection and sacrifice may be too great -that is to say, an inferior training of auxiliary workers who show promise. service may be accepted without any urge for real These plans are determined at every stage by the improvement, because in a technical sense the area operation of a team of highly trained workers in the is covered.It is doubtful whether there is any good health field, who take the responsibility of initiating compromise between these extremes.It may be and maintaining a programme and of evaluating its right in certain circumstances to accept the existing progress.Intheearlystages,especially,sound order of things in the hope that extension will be leadership is indispensable.It matters little how the encouraged. On the whole, the balance of favour programme begins, whether as part of a mass campaign rests with quality, although it must be admitted that against disease, as an ad hoc MCH project, or as a in a few countries the authorities have remained project taking over an existing scheme.The road to content indefinitely with a single MCH demonstration progress is through joint action. centre and have shown no tendency to extend its benefits to other areas.No doubt itis a good show -place for visitors. 3. MENTAL HEALTH In the long run it has paid the best dividends to set up one first -class centre with adequate staffing The care of persons suffering from mental disorder and well -trained personnel.Even when extension is is one of the oldest of the medical functions assumed slow, the original centre has been developed into a by the state.In the past, institutions for the mentally simple training institution and in this way has enhanced ill -like prisons -have always been associated with its own value to the larger community.In this way restraint; and in some countries today the location of also the demonstration centre offers encouragement the two institutions side by side is a grim reminder of to persons of goodwill and so stimulates voluntary coercion.The modern outlook on the care of the effort in other areas.The only risk involved is that mentally sick may be said to have emerged in Italy the demonstration centre may be so elaborate and and France towards the close of the 18th century, perfect that envy is aroused instead of a desire to and the work of Chiarugi and Pinel in those two extend and improve.The exhibit must be within the countries was taken up by Tuke in England and by THE DISTRIBUTION OF FUNCTIONS IN THE HEALTH SERVICES 39 other pioneers in mental hospitals in Europe and staff, and in this way has introduced a scheme appli- North America during the first half of the 19th century. cable to the country and providing a complete and It was unfortunate that little improvement took place coherent system.In general the training of local in building: many countries, as they developed mental staff by an experienced local teacher is more satis- hospital treatment, were content to follow the worst factory in its results than the creation of a number of designs of the period of restraint, making their institu- fellowships abroad. tionslarge,gloomy and barrack -like.Elaborate It is generally of great value to establish, as soon as precautions continued to be taken against escape, and possible, an institution for training (preferably attached ward construction laid emphasis on control by force. to a university) which will serve a group of neigh- The institutions used today by a considerable bouring countries as both a teaching and a research number of countries bear the scars of the old system, centre. A good modern example of thisisthe including a persistent tendency towards overcrowding. Lebanon Hospital for Mental and Nervous Disorders, On the other hand, there are welcome signs of a new which gives special attention to the training of psy- attitude, mainly because national governments are chiatric social workers and nurses.In its own sphere learning more and more about one another, and their the All-India Institute for Mental Health at Bangalore medical, nursing, and architectural staffs are seeing could organize a curriculum fornurses'training for themselves what is being done in the most modern schools in mental hospitals and undertake to maintain institutions.Moreover, many mental health autho- adequate standards.In other countries the establish- rities are finding out for themselves what an immense ment of an association for mental health often provides amount of successful care of the mentally sick can be the necessary initiative for schemes of training in undertaken outside the walls of the hospital, and psychiatric social work and simpler courses in mental have started schemes for the development of out- health service. patient and home care through the agency of clinics The training of medical undergraduates in mental which have trained psychiatric and auxiliary staff. health work is of great importance.Reports indicate In areas where this kind of forward movement is just that in many medical schools the present teaching beginning, the crying need is for trained personnel. consists of a short theoretical series of lectures on In the first instance this may be supplied by visiting mental diseases, with no practical or clinical experience teams, but the essence of the problem is to achieve to add reality to the teaching.In post -graduate the training of local personnel and to secure and teaching also there has been a tendency to cling to maintain the interest of medical and nursing students. methods which assume the continued separation of Mental hospital work has long been regarded as the mental hospital from the general hospital service, inferior in status to general hospital medical and and mental from physical illness.In a number of nursing service, with the result that salary scales in countries the remuneration of psychiatrists has been such institutions are not attractive; or perhaps these so low that men who have taken special training two factors interact.Mental health work will not abroad and acquired the highest qualifications in the make real progress in a country until there are trained subject have returned home only to go back into counterparts in that country of all members of the general medicine. visiting team, at every level of professional skill-psy- Reports from various authorities indicate that, even chiatry, psychology, psychiatric social work, nursing, in the smaller countries, there is still a tendency to and auxiliary work.Following upon initial visits to build far too large mental hospitals.The optimum an area by a team of consultants, at the request of a capacity is probably between 300 and 400 beds, so as government, itis sometimes necessary to take the to permit of a relatively non -institutional atmosphere first step in training by sending local staff on fellow- and the opportunity to create occupations, both ship grants to institutions abroad where they can indoor and outdoor, which can be supervised without obtain suitable instruction and practical experience developing a kind of factory system of control.In of a mental health scheme.The object of such Malaya, for instance, the size of the central hospital fellowships should be to create a body of local teachers, is 3000 authorized beds, and the immediate need in not to provide an institutional staff. A system which the country is to provide a well- distributed series of is in many ways more desirable, however, has been smallerunits.Similardifficultiesare obvious in put into operation in Taiwan.In this case the head other countries, notably in those that have had the of the department himself undertook a fellowship longest experience of State control of mental illness. study and visited many institutions in various parts The mental hospital is only one element in a fully of the world.On his return he himself has provided organized mental health service.Even as an institu- the necessary training and practical work for local tion its usefulness is limited in some degree by its 40 FIRST REPORT ON THE WORLD HEALTH SITUATION specialization.For this reason a great number of At the present time one does not think of mental authorities have been establishing mental health units hospitals without at once contemplating methods by in general hospitals, associated as a rule with highly which people can be kept out of them.This is not developed out -patientdepartments.Oneofthe just due to the fact that most mental hospitals are important functions in the earlier days of this advance shockingly overcrowded in most countries of the was to deal with patients who feared the mental world.It is one facet of the more important finding hospital because of its unhappy associations with that many patients do better when they are treated compulsory detention.In the more fully developed wholly at out -patient clinics, sometimes following a countries this disadvantage has been largely negatived short period of in- patient observation or intensive by the growing provision for out -patient care at the treatment.Studies of the actual patients in mental mental hospitals themselves, and even more by the hospitals often reveal that only a small proportion of system of voluntary admissions without any form of them really need hospital care, if the alternative of certification.It has now been widely recognized suitable home care can be provided.In a study of a that certification, or compulsory admission, should mental hospital in the Eastern Mediterranean it was be regarded as a last resort and not as a necessary found that the development of a colony scheme would preliminary to treatment.The units which are being greatly reduce the need for in- patient care and, of established at general hospitals, however, serve a course, the cost of treatment.In other cases it has special purpose, although by no means exclusively; been shown that, given suitable out -patient care, less they are in the best position to deal with patients than half the number of inmates required either medical suffering from the psychoneuroses and also those or nursing attention. afflicted with psychosomatic illness.In a consider- The mental health of children is a subject to which able number of cases they are well suited for dealing increasing attention has been given in the more with the more serious mental illnesses of children. recently developed countries.In time past Italy and An additional feature of mental care in the general France have shown how much preventive and pro- hospital is that it offers unusually good scope for the motive work can be achieved through the intelligent operation of the " clinic team ", which has now care of young children by kindergarten and nursery become such a feature of mental health care in schools.Valuable studies and projects of a similar Great Britain and in the United States. of America. kind, but with striking individual variations, have And, finally, the general hospital clinic becomes a been a special feature of health promotion for children valuable diagnostic centre for early cases and for in Germany, Austria and the Scandinavian countries. consultation between the psychiatrist and the general A great deal has been accomplished by voluntary physician. services in Belgium and the Netherlands, for preventive In addition to the construction of mental and work lends itself especially to voluntary effort in the general hospitals there is, in the larger countries at care and education of children.In the more specific any rate, a case for the building of a national institute field of mental health care the schemes of child of mental health.The special usefulness of such an guidance, in which the United States of America has institute is that itis in a position to concentrate taken a leading part, were begun in the first decade attention on and to secure the balance of all the of the century and carried forward with great vigour various mental health services.The National Insti- after the First World War by such organizations as tute of Mental Health in Japan is a good case in point, theCommonwealth Fund.Itwasthroughthe becauseitexercises leadership in this branch of agency of that Fund that child guidance became health work, partly by its central position and partly established as a service in the United Kingdom. by setting up model clinics and other services.It is Child guidance has proved to be an excellent example also able to maintain a library and to publish a of the value of team -work in mental health, and it is journal, through which research advances are made significant that in many areas child guidance centres widely known.In the European countries, especially have become part of the educational system, bringing in the north, mental hospital provision has long been the teacher into the team as well as the psychiatrist a State function, and most of the hospitals are either and the educational psychologist.On the other hand, State institutions or are heavily subsidized and con- it is to be remembered that child guidance includes trolled,usually by thecentral department.The therapy, and for younger children, as well as for preventive mental health services, on the other hand, schoolchildren showing early signs of certain types are as a rule operated and in some cases wholly of behaviour abnormality, attendance at a special supported by voluntary organizations on a commun- child guidance clinic is the first condition for successful ity or regional basis. treatment. THE DISTRIBUTION OF FUNCTIONS IN THE HEALTH SERVICES 41
A number of services relating to mental health are garden, pigs, chickens, facilities for haymaking and, essentially part of an educational service to the same in addition, a great many indoor occupations, includ- extent as school health inspection and the specific ing such jobs as book -binding, mat -making, dress- health education of children in school.The same is making and laundry work.The patients are paid of course true of the training of educationally sub- only pocket money for their work, which is mostly normal children. A special school has now been set used by the community itself.They are not usually up in Iraq, and any measure of this kind is an important permitted to work fortheir own foster families pioneer venture.There is a strong case for govern- for fear of exploitation.Family care seems to be ment support for voluntary efforts in the promotion most suited to chronic psychotic patients and to of mental health, especially in the child population, certain types of neurosis. and this is most effectively carried out by the generous A most interesting experiment along similar lines support of associationsfor mentalhealth.The to that of Gheel is a recently established neuropsy- Egyptian Association, for example, was created in chiatrie day hospital in Western Nigeria.1This new 1940; its membership includes psychiatrists, psycho- hospitalhasa genuine community development logists, and a great variety of educational workers, situated in beautiful grounds of extensive area (1 mile and it is linked with the World Federation for Mental square).All the members of the staff are resident Health. and there is a programme for accommodating essential One of the most valuable methods of dealing with artisan employees and labourers in a village com- mental patients is the system of family care.In some munity centre within the hospital grounds.Patients countries, such as the United Kingdom, it has not attending the day hospital are boarded out in the been prominent except in dealing with mental defect- neighbouring villages and come in daily for treatment, ivesunder guardianship.Thissystem,especially spending the rest of the available time in a department when the defectives are settled with foster -parents, of occupational therapy.They return to the villages works very well.There are also in a considerable in the late afternoon having thus combined active number of countries provisions for boarding out treatment and rehabilitation. mental patients, but this measure has not been applied The patients who are boarded out are, of course, to a very great extent except in a few European coun- specially selected.They are accompanied as a rule tries.The system was first introduced many years by the relatives, usually the mother, ora sister, ago at Gheel, in Belgium, where a small mental brother, etc., and most of them come from distant hospital service has a centre for more than 2500 pa- areas. A nurse is always on duty in the villages at tients who livein the surrounding districts.In night to cope with minor nursing difficulties, and she Norway only half of the certified mentally ill patients can send for help to the hospital in any emergency. are cared for in mental hospitals; 39 per cent. are in A guide is also provided by the hospital to look after family care under supervision from a mental hospital the relatives of patients from distant areas. (3 per cent.) or under state supervision (36 per cent.). The present clinical facilities consist of modern The remainder are looked after in nursing homes, electrical treatment, insulin therapy and the whole often under private management.Privatefamily range of psychotherapy measures and drug medica- care gives rise to a good many administrative diffi- tion.Special emphasis is placed on occupational culties, and in some cases patients miss the skilled therapy and other group activities as an essential part attention which they would receive under hospital of rehabilitation.It is planned in such a way as to guidance.On the other hand, there are great advan- give patients from diverse social backgrounds every tages in surrounding a patient by home conditions, opportunity to follow the kind of work which they and many of them do well in the absence of an institu- understand: rough types of labour are encouraged tional atmosphere.In some ways it is surprising to and little huts have been built to preserve a village find how few complaints are made about a patient; atmosphere.At the same time there are facilities for and the crime rate among the patients in family care painting, weaving, knitting, etc., in a well -designed is much lower than among the general population. building. In the Netherlands the development of family care One of the drawbacks in family care, unless the in the city of Amsterdam is well known.The early system is well centralized, is the lack of provision for example of Gheel has been followed there, notably at organized occupational therapy.This is a develop- Beilen.One of the special features of the Beilen ment which has gained much ground in mental colony is that great attention is given to occupational therapy.Most of the patients work each day, both LAMBO, T. A. (1956) Neuropsychiatrie observations in the morning and afternoon.The centre has a market Western Region of Nigeria.Brit. med. J., 2, 1388 42 FIRST REPORT ON THE WORLD HEALTH SITUATION hospitals during the past two decades and has proved disease goes back as far as Ramazzini, but wider and its value again and again in the improved outlook of more specialized studies date from the industrial patients and in their whole attitude towards hospital revolution in the late 18th century.At that time, care.Among the mentally sick, arrangements for and for nearly a century later, workers in the field rehabilitation through occupational therapy and the of industrial health and their advocates in public life provision of interests are of the utmost value and had to fight against a laissez -aller attitude on the supply the needs of a very considerable proportion part of many employers and an economic theory of the patients.Much recent work has been done which paid more attention to successful competition on the subject and the scope of occupational therapy than to the needs of those who produced the goods. has been greatly widened.Indeed one of the out- In the course of the 19th century it became clear in standing faults of some of the mental hospitals that are industrialized countries that some form of protection being built today is that they do not provide ade- of the workers' health was essential to human welfare quately, either in staff or in space, for occupational and dignity.At first, legislation was introduced to therapy. prevent the grossest abuses, especially the exploitation In the long run the success which countries achieve of women and children, but in the early days there in their mental health plans will depend to a very were no means of enforcement by inspection.Gra- great extent on the skill and persistence with which dually, in response to political and social pressure, the authorities apply themselves to the prevention of there grew up a code of laws and regulations and an sickness and the promotion of health.On the effective system of supervision.In the course of strictly preventive side a great deal is being done by time a great body of highly specialized industrial law skilled psychiatric approach to children who are has been created little by little in response to hazards showing signs of early trouble.This approach is as they have become recognized. best organized by team -work through which both the children and their parents are dealt with and the Industrial and occupational health services social and environmental circumstances are carefully watched. A great deal can be done -perhaps more The promotion and maintenance of industrial than in any other sphere of medicine -to achieve health and hygienerequire ahighlyspecialized positive training in mental health as a public service. organization in both the engineering and the medical Mental health education is a skilled job and itis field.The two work together in an integrated service. most successful when itis continuous and unob- The technical problems that arise are innumerable. trusive.So much depends, as Bowlby and others They concern the structure of the factory or work have shown, on the fundamental relations between place, the provision made for general hygiene, good the young child and his parents and the affection lighting and ventilation, as well as consideration of which he receives as a member of the family. A the maximum comfort of the staffs concerned.In a great many disasters have been caused by broken more specialized way the inspector of factories has to homes and the general ill effects upon a young child see that appropriate provision for the health and who is deprived of normal family life. safety of workers is carried out in each particular process.Long experience has shown that certain industries, such as mining, lead- working and trades 4. OCCUPATIONAL HEALTH involving contact withsilica,expose workers to specific hazards, and special precautions are under- Itis more satisfactory to describe the aims of taken to prevent their ill -effects.These are merely occupational health than to attempt a definition of minor illustrations of an enormous, highly complex the term.Occupational health aims at the promotion group of industrial processes which require close and maintenance of a high level of physical, mental supervision and constant vigilance to see that regula- and social well -being of workers in all occupations. tions are observed by both manufacturers and workers. Its object is also to protect workers from the hazards These technical provisions are not by themselves of sickness or accident due to their employment.It effective in achieving occupational health in the broad is the duty of an occupational service to do everything sense.The personal health of the worker and his possible to place and maintain workers in an occupa- suitability for the job he undertakes involve an assess- tional environment suitabletotheir mental and ment for which special medical training is indispens- physical capacities. able.The industrial society of our day, over and Research into the relationship between work and above the specific hazards mentioned, imposes its sickness and knowledge of the causes of industrial own patterns of stress and thereby introduces new THE DISTRIBUTION OF FUNCTIONS IN THE HEALTH SERVICES 43
medical problems directly or indirectly associated co- operates with all persons who take part in the withtheindustrialenvironment.Theindustrial protection of the health of workers.He maintains health service has therefore widened its scope to take close contact with the neighbouring hospitals and into consideration not only the health and safety of health centres and at the same time keeps in touch with the person and the maintenance of a good environ- occupational health institutes and research activities. ment but also the integration of a complete service The employment of a full -time physician with the in which a team consisting of physician, safety engineer duties outlined above has been verysuccessfully and other experts work in harmony.This has been organized, especially in certain industries which have fully developed, for example, by the Tennessee Valley developed on a large scale in recent years both in the Authority in the United States of America. United States of America and in European countries. In an industrialized society it is essential that all This applies particularly to the motor industry, and general practitioners should have some knowledge of there are some conspicuous examples of such medical occupational health so that in their practice they will services in the United States, Great Britain, France not fail to observe and report any diseases which seem and Germany.The radio industry has also achieved to be prima facie associated with employment.Over a high degree of efficiency in its medical service - and above this, however, some physicians have a perhaps the most notable example being that at more direct responsibility for the protection of the Eindhoven in the Netherlands.But in addition to health of employed groups either by providing, along these instances, a number of the older industries, with their general practice, a part -time service in some of a very heavy character like steel production, industrial undertakings or by performing these duties have introduced admirable full -time services with a on behalf of government or industry on a full -time wide range of preventive and curative work -a basis. A part -time industrial physician requires a striking example of this being in the new steel town more extensive knowledge of industrial health pro- of Corby in Northamptonshire, England.In certain blems than does the general practitioner, as he is other areasfull -time medical services have been dealing with them in his daily work; and in addition organized from a special industrial centre or institute, he requires a more intensive knowledge of the parti- as in the case of Helsinki, Finland.There are many cular industrial activity with which he isdirectly patterns of this work which would serve as demonstra- connected.It is therefore not uncommon for a full - tions to countries which are advancing industrially time industrial physician to be associated with a at the present time. particular industry or group, and he thus acquires a The first condition of a good industrial health special knowledge of all the medical problems that service is provision for research.In a number of arise in the course of his work.He is in close touch industrialized countries today special institutes have with the management, the safety engineering and all been set up, notably the Institute of Occupational preventive services.At the same time he is responsible Health in Helsinki, the Institute of Occupational for clinical services, especially for accidents and first - Hygiene in Oslo, and laboratories and special depart- aid provision of every kind with special reference to ments in many other countries.The research work the particular hazards of the industry with which he performed by institutes and laboratories falls na- is concerned. A great deal of his work is devoted to turally into two groups: (a) basic research; (b) prac- promoting and maintaining the health of the workers, tical research to meet national or local problems. and the physician is especially concerned with assessing Fundamental research is being carried out in practi- fitness for work, both in general and in relation to cally every industrial country, but in some the definition particulartasksordepartments.Theindustrial of industry is perhaps too narrow.The word " occu- medical officer acquires a good knowledge of the pation ", on the other hand, has a clear and well - whole working organizationof theindustry;he definedmeaning.Eveninhighlyindustrialized should be able to assess the influence of the working countries the establishment of institutes has been environment on common diseases, absenteeism, labour comparatively recent -for example, the Clinica del turnover and the functions of the personnel depart- Lavoro was founded in Milan in 1904.An occupa- ment.In more general terms he studies the occupa- tional health institute could be defined as" any tional factors leading to fatigue, accidents, failure of organizationin whichspecialistsinthevarious adaptation, psychoneuroses and occupational diseases. branches of occupational health act together as a Inco- operation with the personnel manager he team to conduct research and teaching and to provide accepts the fact that the worker is at one and the same service in this field ".It is undesirable that there time a wage- earner and a member of a social group. should be any fixed pattern of institute, but itis Inside and outside the factory the industrial physician clearly wrong that the institute should concentrate 44 FIRST REPORT ON THE WORLD HEALTH SITUATION solely on pure science at the expense of practical health and safety. A large number enforce legislation service.By this means it quickly gets out of touch for the prevention of occupational disease and acci- with everyday problems and loses its position as an dents.Pre -employment and periodic medical examin- instrument for promoting occupational health in the ations are frequently required for young workers and social sphere.Practical activities include an enor- for those whose occupations involve certain special mous variety of local problems and this is the core of hazards, such as contact with silica and exposure to an institute's research work.The nature of the radioactivity.In the majority of countries provision research has usually been determined, first, by the has been made for factory inspection, generally under interests of the members of the staff; secondly, by the ministry of labour, as in Japan, Norway and the the problems actually presented under local or national United Kingdom.In a considerable number of industrial conditions; and, thirdly, by the appearance countries,on theother hand,responsibilityfor or indication of special hazards, such as pneumo- occupational health is assumed by the ministries of coniosis, asbestosis or byssinosis.In a purely research public health, as in Argentina, Chile, Mexico, Peru, institute the problem sometimes arises about the and other countries of Latin America.In Australia amount and extent of work that should be undertaken and New Zealand industrialhealthservicesare on behalf of the industrial firms requesting assistance. integrated with the state health departments, while This problem has presented itself in both Canada and in the Union of SovietSocialist Republics and the United States of America, as well as in the United Yugoslavia occupational health supervisionisthe Kingdom.There is always a risk that the needs of responsibility of regional public health officers.Some research might be obscured by more or less routine of these countries have separated the inspectorate inquiries or by frequent demands from industrial fromthehealthsection,asinthecaseof firms to undertake investigation, not so much in the Egypt.In the United States the factory inspection interests of research as in the promotion of commercial services have no medical functions and there are advancement.There is no general rule in this matter industrial hygiene units in the various state depart- but institutes and laboratories have now and then ments.In France, legislation has been enacted to been overwhelmed with routine services to the detri- extend the scope of factory inspection, and in 1946 ment of their research. the law required that every factory, regardless of size, As has been indicated, occupational health is a should establish a systematic medical service.Em- wider term than industrial health.It covers many ployers are obliged to provide facilities for annual employments, including domestic work, which would medical examinations of the workers (including chest not be classified as industrial.The home exposes its x- rays), first -aid services, and a special system of job inhabitants to many hazards, especially accidents to placement. children and the aged.The problem of accidents in A growing number of countries provide general the home has given rise to anxiety in many countries medical care for workers, and this system is perhaps and special measures have been taken to deal with more advanced than in many other health services. these risks.In this work voluntary societies for the Many of the health insurance systems started by prevention of accidents in the home have carried out covering occupational groups,extendinglaterto pioneer work, especially in the United States, Great widersectionsof thepopulation.Thisgradual Britain and Belgium.Perhaps even more important coverage has applied to the United Kingdom, Japan, than general education is the contribution made by Turkey,India,andothernations.Many large government and industry jointly to building up new industries have provided their own insurance and generations of workers who are conscious of the need compensation systems, and some special industries for protection against hazards in the home as well as are required to do so by law -such as, for example, in industry.Safety in the home ought not to be rubber- and tea -growing on the estates in Malaya ignored, and the mere fact that the approach is less and Ceylon.Finally, it is important to observe that precise does not prevent the organization of teaching in an increasing number of factories organized health such matters as personal hygiene, accident prevention, services have extended beyond the walls of the factory use of leisure, the need for proper rest and sleep, the to the families of industrial workers.In some areas dangers of over -indulgence in food, alcohol and which are now developing, these services are the tobacco, as well as the means of preventing com= nucleus of a national health service organization. municable diseases. They are at any rate an indication that many nations Very few countries that today have reached a high are beginning to realize that sooner or later there will status of industrial development are without a com- be a fusion between the health services for the worker prehensive organization for research into matters of and those provided for each family. THE DISTRIBUTION OF FUNCTIONS IN THE HEALTH SERVICES 45
Vocational training and functional restoration arerecommended togetherwithsuggestionsfor training.It should be a function of the institute to The process of rehabilitation, as has been pointed promote research in rehabilitation and vocational out, should begin at the moment of injury; should training. continue through the whole of hospital and convales- cent treatment, and, finally, should be linked with 5.HEALTH EDUCATION the process of returning to full functional activity. These are the aims, but in many circumstances the Health education is one of the most stimulating of return to functional activity and to the original job subjects, because in many countries it is a relatively is not feasible.In this case rehabilitation measures new field, offering abundant scope for initiative and take the form of training either for a completely new experiment.There is no short -cut to health educa- job, where the disability is serious, or for a lighter and tion by any programme of universal application. more appropriate job in the same industry.Where Each government finds that it has to devise plans young workers are concerned, this type of training, best suited to its own background and the attitude which normally lasts for a considerable period (i.e., at of its people.Nevertheless, those who have been least two years),isfrequently called" vocational working during the past few decades on the content training ".For older workers and especially for of health education have established certain principles those who can be returned to work in the same of general application.They have also been able to environment,the word " rehabilitation "is more experiment practically withdifferentmethods of commonly applied. reaching the public and have made steady progress In the more industrialized countries rehabilitation along these lines. is generally continued without a break from the out- Among the principles of health education are one patient department of a hospital to a special unit in or two which stand out prominently.In the first the industry itself.In the great industries of the place, it is not an isolated subject: it is part of the world there are notable examples of rehabilitation educational process and is applicable to every age and service.One may mention in passing the Ford stage in human life at which learning is possible.It factories in the United States of America and else- must be integrated with general education for child where, the Austin and Vauxhall automobile works in and adult alike.Secondly, health education -no less England and the Philips electrical industry in the than any other, perhaps more complex, subject - Netherlands. A more general system of rehabilitation cannot be successfully inculcated unless its teachers is being increasingly applied by government depart- are properly trained in its content, method and pre- ments on a national or regional basis.Thisis sentation.Thirdly, the teaching of health is not an necessary because a great many industrial firms are isolated process :it requires team -work of a high not large enough to undertake any considerable order -that is, full collaboration in both training and scheme of rehabilitation.It is also of value in many practice with allied disciplines such as clinical medi- countries, because schemes of this kind enable re- cine, public health, nursing education and the social training to be carried out in an environment which sciences.The fourth principle -and it is one which may well be more suitable for the workers than governments are appreciating more and more -is ordinary employment.This is especially applicable that health education cannot effectively be carried when a worker has to be moved to some totally out in fits and starts : it must be essentially a continuous different type of employment -for example, from a process undertaken in close working contact with the heavy to a light industry.Mexico and Norway, people.This is not to deny the potential value of among many other countries, have introduced schemes special propaganda efforts such as " health weeks " of this kind.The task of a considerable number of and special exhibitions, which serve to illuminate these rehabilitation schemes is greatly advanced and brightly a limited subject for a limited period; but lightened by the assistance of voluntary organizations. these special efforts cannot take the place of continuous In summary, the work of rehabilitation in a unit, patient teaching among the people themselves. however formed,is :(a)toassist the authorities, In the early days of health education programmes, hospitals, voluntary organizations, social insurance as is shown in the reports of certain countries for the authorities, etc., by the careful examination of disabled years 1954 -56, there has been a certain amount of persons with a view to their rehabilitation or voca- public resistance to this kind of approach.The line tional training; (b) to establish a plan of rehabilitation of argument has been: " We are surrounded by sick- for each disabled person in which the necessary ness and we ought to use all our money and effort on treatment, appliances, and physiotherapy measures building hospitals to cure the sick.Then, and then 46 FIRST REPORT ON THE WORLD HEALTH SITUATION
only, can we begin to talk about health ".In its A number of countries have indicated in their replies crude form this argument contains obvious fallacies, that health demonstrations are given from time to but it also carries lessons which should not be ignored. time, and that posters, cinema, radio and television In some countries in which the sickness rate is high, are used regularly to educate the public.In one and especially in malarious regions,itisnatural instance it was frankly stated that the people did not enough that the stricken people should look with a appreciate filmed talks, because they did not under- sense of envy on the great hospital centres of the stand the language in which these were given. Another wealthier nations and feel that they have been deprived government authority gave the disarmingly simple of something or put off with an inferior article in the answer that health education was provided by mid- world market of medical care.This very attitude, wives in the homes of the people. A third, with a ill- informed as it is, offers a clue to health promotion shrewd sense of the realities, replied that its only in some of the areas which are oppressed by sickness. effective educational system was in the schools, and To such countries it is necessary to bring, in the first that health education had been developed by the instance, some of the benefits of modern medical teachers, who had received a course of training for treatment. A series of dramatic cures helps to gain that purpose. the people's confidence and to prepare the way for It is quite clear that in many countries, as they their co- operation.For it can be said categorically progress towards a fuller concept of health education, that no programme will win more than a temporary the emphasis is shifting from more or less spasmodic success unless it achieves active co- operation from propaganda to comprehensive and continuous activ- the people themselves.Ignorance breeds prejudice. ities.When health education programmes started, At this level the value of team -work between workers few countries had any department or division res- of different backgrounds is apparent.It offers all the ponsible for work of this kind.The result was that advantages of a strategic, rather than a forceful, in many instances the programme was handed over advance.In some cases it may be the clinical member to an existing section, which had perhaps only a of the team who makes the first score, and in others limited function in the health services and may be the nurse or the engineer. A number of government none at all in education. authorities, for example, have offered some resistance As time went on, more and more governments to the medical approach, but have worked eagerly in began to establish at least a technical division of an environmental sanitation project, such as the reduc- health education in their national departments of tion of flies by means of an effective system of latrines. public health.These divisions gradually became As often as not, an education project is made accep- represented by sections devoted to the subject at the table by a simple sanitary demonstration.The stra- provincial or municipal level.This development had tegy lies in adopting the road that presents the fewest both theoretical and practical advantages.On the obstacles. theoretical side it provided a service, while from the At a different stage of national development it may practical point of view it was economical by its not be necessary to employ the therapeutic or environ- assistance in the provision of locally planned illus- mental approach.The country may have good hos- trative material which could be duplicated and widely pitals and clinics;it may have adopted successful distributed.Another great advantage of central methods of combating malaria and yaws, or launched development, as many authorities have found, is that a campaign against tuberculosis.The battle against it helps to bring together the main departments con- sickness is being won, yet the campaign for health cerned with the subject -especially health and educa- may be lacking.The replies received from govern- tion.In addition,itenables these authorities in ments show that many countries are anxious to go combination to create a sound scheme for training forward, and yet their step falters because of a con- professional and auxiliary health workers of various fusion of thought between the conquest of sickness on categories. the one hand and the promotion of health on the It has generally been found very helpful to begin other.It is true, as we have seen, that a plan for the a service of this kind with the temporary appointment elimination of a disease such as malaria, yaws or of a consultant who has had long experience in different trachoma may be the means by which a health educa- areas and is in the position both to study the needs tion programme is introduced -and it is certainly an at first hand and to draw up an appropriate pro- admirable basis for a health education study to ascer- gramme. tain what practical measures are needed and how best Where schools are comparatively undeveloped, for they can be applied. But the limitation of disease is by example, it may be necessary to attach health educa- no means synonymous with the promotion of health. tion actitivies to other groups such as the maternal THE DISTRIBUTION OF FUNCTIONS IN THE HEALTH SERVICES 47
and child health service, or to place health education, soon gained inthelocal teaching schools.The at least for the time being, under the aegis of a specific teaching of graduates is, however, a relatively slow campaign, e.g., against malaria or some other wide- and long -term process, and as a result of this a number spread disease.In one territory,for instance,a of institutions held short -term courses in 1956 to meet health education study is being conducted in con- the needs of workers in the field.Not infrequently junction with a bilharziasis control project. In these courses have been attended by professional others, the presence of such conditions as trachoma, workers from a wide area, especially in the Pacific malaria or hookworm may provide the initial stimulus. region.The short courses are usually conducted by However this may be, the attachment of these projects a teaching staff representing a number of selected must be regarded as a temporary measure of introduc- subjects, such as social anthropology, social psycho- tion rather than as a permanent activity.Health logy, public administration, health education, teacher education work is an integral part of the regional training, and environmental sanitation. programme and of the public health service of any territory, and the most satisfactory schemes are un- questionably those which meet the needs of a large 6.DENTAL CARE number of groups.It is in this way that the health workers have a first -hand knowledge of the people, The progress of dental health in the more recently their culture and traditions, their way of life and, developed countries has been profoundly restricted above all, the ways in which they are most open to by the shortage of trained personnel.This applies approach and to ultimate co- operation.In some of both to training schools and to the number of prac- the less developed areas it has been found desirable titioners available.In the smaller and more scattered to undertake a preliminary survey through the agency territories the first step in promoting a dental scheme of a social anthropologist, because of his knowledge has usually been the appointment at headquarters of these very features.Where school organization and of an experienced dental officer to survey the country's literacy are more advanced the training of teachers in position and to report on the more urgent needs.In health education methodsisprobably the most the less populous areas there is a desperate lack of satisfactory approach; and in the highly developed dental officers of any kind, public or private, trained countries health education can play its own part in the or untrained.In such areas, patients urgently needing team -work of the public health and educational services. attention are seen at the various hospital out -patient Whatever methods of teaching may be adopted in clinics and occasionally at health units in remoter any country, one of the earliest steps forward consists districts.Attached to the central department's staff in organizing a system of training within the country it is now not uncommon to find a senior officer with a itself.This applies to professional workers of various a few full -time dentists under his immediate charge. kinds, including medical, educational and social. It is out of the question for these officers to cover Yet unfortunately it is at this point that apparently the more than a token portion of the territory, but they least progress has been made up to the present time. may at least have an opportunity of supervising the Governments have gladly accepted advice and help work in schools; and it is frequently there that fairly in the preparation of an initial project, but some of complete dental work isundertaken.For adults them have faced difficulties in moving towards the some reliance can be placed on private dentists, and next phase :the deliberatetraining of their own in the more scattered territories a number of these professional groups to undertake the health education have been trained in an accessible centre and can be programme.There are certain methods of dealing classified as " assistant dentists ". with thisdifficulty, which some authorities have Among the larger problems of many lands the accepted.The first is the introduction into various question of fluoridation has become the subject of professional courses, such as pedagogics, medicine, public controversy.As far as the dental profession nursing, and social sciences, of instruction and practical is concerned there is a general agreement on the value field work in health education principles and methods. of fluorides as a preventive measure; discussion and This has been done successfully in a number of areas research are now concerned with optimal quantities especially for the post -graduate range, including, in and methods of administration. the case of one country, public health administra- The earliest studies of fluorides, made over 20 years tion, hospital administration, public health nursing, ago, related to the ill effects of excessive quantities in and environmental sanitation. water supplies.It was shown that the continuous use At first it may be necessary to introduce experienced of water containing more than one part per million teachers from universities elsewhere but momentum is might lead (in about 10 per cent. of cases) to mild 48 FIRST REPORT ON THE WORLD HEALTH SITUATION degrees of fluorosis, and that the disturbance in tries the percentage of decay affecting the teeth of enamel formation increased progressively with the children dropped in certain groups to about 75. concentration of fluorides.During this period, dental Sincethewar,however,sweetsand sugar -con- scientists observed that dental caries could be checked taining food have become more plentiful, and the by the topical application of fluoride solution.This curve of caries has risen once again.It is clear that was proved in practice by an extensive experiment on diet has contributed to this change to a considerable schoolchildren.Following these studies an important extent and the main element in it has been the con- step forward in preventive dentistry was made by the sumption of sugar and other highly refined carbo- discovery that a moderate quantity of fluoride in hydrates.At the same time the diet under the food - drinking -water was an efficientprotectiveagainst rationing system in operation in certain countries was caries.Surveys in natural fluoride areas have shown so organized as to give preference to expectant and that dental caries prevalence is reduced by as much nursing mothers and to young children, all of whom as 65 per cent. by the continued use of one part per received relatively more protective foods.Thus two million fluoride.The good effectextendstoall factors combined to produce the wartime decline in children in whom the permanent teeth are already caries.In addition to the harmful influence of diet affected with caries, although not, of course, to any there is no doubt that food can provide positive nutri- great degree. tional value in the prevention of disease. This applies A third method of supplying fluorides has been mainly during the formative period, and a properly suggested and tried.This consists of the addition of balanced dietis therefore especially important for a known quantity to the daily diet -especially that of expectant and nursing mothers and young children. children.The results of the trials were good, but the Dental treatment should be concentrated, as a public drawback to this method is the need for expert super- health function, on the expectant and nursing mother, vision owing to the uncertainty as to the amount that the pre -school child, the schoolchild and the young might be ingested. adolescent.During childhood the healthy develop- In many parts of the world periodontal disease has ment of dentition will determine the strength of the been reported as the most outstanding problem at the adult teeth. Supervision by qualified dentists during present time and a number of special studies on this the growth period istherefore of the utmost im- complex subject are being undertaken.The distribu- portance, not merely in the prevention of caries but tion of the disorder is curiously irregular.It affects also in the correction of abnormal positions during the large population groups of nearly all ages and, in development of the teeth and jaws.In all countries general, the incidence and severity increase with age. where the dental service is limited children should Periodontal disease is consistently higher in boys than have the priority. in girls -in fact in males of all ages. There is now general agreement that the training One of the obvious difficulties in providing steady and employment of auxiliary dental staff in the health progress in dental care is that, in contrast to the attack service promote economy and a wider range of pre- on some of the major communicable diseases at the ventive work, always provided that the auxiliary present time, dental treatment is so personal and so personnel are supervised by trained dentists.During time -consuming.There is no campaign on a broad the past generation or so dental hygienists have been front.There is no panacea.For most of the dis- trained and the system of school dental nurses has orders of the teeth treatment demands the personal been introduced. A number of years ago the South attention of a qualified dentist assisted by a technically Pacific area met some of its most urgent needs by the trained staff and making use of elaborate and costly training and appointment of assistant dental prac- apparatus. Even in the most advanced countries dental titioners.This system now shows a healthy tendency care falls short of the admitted needs ;a relatively to spread to other countries in which dental care falls good ratioisone dentist to about 2000 people. far short of the needs of the people.There has been Preventive work is, of course, the ideal, but decay still a certain amount of resistance to the appointment of wins in the race. auxiliary workers, but the advantages are now shown From the world point of view the preventive to be overwhelming.This is especially true where the approach is the way of choice, and certain aspects have number of qualified dental surgeons is inadequate to very properly received special consideration.During meet the needs of the country even for emergency wartime, with the restricted intake of food -especially treatment.There are countries in which the ratio of food containing sugar and other enemies of the of qualified dentists to population is as low as one to teeth -there was a great reduction in the frequency of 350 000 (compared with one to 1700 in some of the caries.It was reported that in some northern coun- more advanced areas).Auxiliary staff in team -work THE DISTRIBUTION OF FUNCTIONS IN THE HEALTH SERVICES 49 is also desirable where there are enough dental sur- tion ratio.From a figure of 114 extractions to geons to meet normal needs but not enough to supply every 100 fillings in the first year of the service there an organized system of preventive treatment for was a steady reduction until a level was reached, children.The introduction of these auxiliaries, espe- in 1946, of 6.3 extractions to 100 fillings -a ratio cially in the Pacific regions, has now progressed so far that has remained constant ever since. that special training has been introduced, and the Assistantdentalpractitioners,under a system auxiliaries work successfully under proper supervision. established in the Western Pacific Region in 1937, The work of the three groups of auxiliaries- dental undergo a course of training occupying three years. hygienists, school dental nurses and assistant den- They are trained, like assistant medical practitioners tal practitioners-differs somewhat in responsibility. in the same area, at the expense of their government Dental hygienists, for example, were trained mainly and can practise only under the direction of trained to undertake preventive work for children and to give dentists and asofficers of a government service. instruction in the care of the teeth. A two -year In 1950 the system had grown to such an extent that period of training was introduced.The main func- it became important to establish uniform standards. tions of dental hygienists are : Facilities were therefore set up at the central school of the area and a new dental school has been estab- (1)examination and charting; lished.There suitably educated young men from (2)prophylaxis -that is, the maintenance of mouth various islands in the South Pacific undergo training cleanliness and the attention to conditions which and return to their own island to work under direction might lead to decay; and as assistant dental practitioners.They are able to (3)dental health education. carry out all the ordinary work of a dentist and receive instruction in the elementary details of orthodontics. The scope of these hygienists was rather limited, In summary it may be said that three types of and their responsibilities were extended by the intro- auxiliary personnel can be recognized:(1) Dental duction of school dental nurses.This system of hygienists, who are trained and employed in the auxiliaries, which was introduced in New Zealand, United States of America, the United Kingdom, has since been organized in other countries.The and some other countries.They are not registrable as nurses are part of the health service; they do not dental surgeons and work only under qualified super- practise independently nor are they employed by vision.Their work is chiefly preventive and educa- private dental practitioners. A very comprehensive tional.(2)Schooldentalnurses (New Zealand course of two years has been introduced and special pattern).These nurses are trained and employed in attention is devoted to instruction in health education the public dental health service to supplement the and to such matters as first aid and general care. work of the dental surgeon.They are not licensed as Dental nurses have to pass examinations at various dentists and their work is limited to children.They stages of the course.After training, they are appoin- do, however, carry out fillings and extractions and ted to dental clinics attached to primary schools, undertake educational work.They are only per- and are normally stationed with a trained dental nurse mitted to work in the State health service and only in the first instance.They work singly or in pairs under the supervision of dental surgeons.(3) Assis- according to the size of the school or group of schools tant dental practitioners (South Pacific pattern). These in their care and they are appointed on the ratio of practitioners are employed by the government and approximately one to 500 children.Their duties are carry out dental treatment for patients of all ages. to maintain a group of children in sound dental health, The system is applicable to countries in which there to teach them oral hygiene and how to prevent dental is a gross lack of trained dentists and particularly disease.Treatment is standardized as far as possible, where scattered populations, as in island areas, make consisting in preventive work, the application of it difficult to establish an organized service of fully sodium fluoride, fillings in permanent and deciduous qualified dental surgeons. teeth, and, where necessary, extractions under local anaesthesia.The nurses do not deal with the more technical procedures but are taught to recognize the 7.NUTRITION needs and to recommend the parents to seek the care of fully qualified dental surgeons. The results obtained In the field of nutrition the distribution of functions by using dental nurses are highly satisfactory.There in health services must be seen in the light of organiza- has been a steady improvement in the dental health of tion at both national and local levels.Most countries schoolchildren, as shown by the annual filling -extrac- have some kind of structure for a nutrition service at 50 FIRST REPORT ON THE WORLD HEALTH SITUATION the national level in their ministry of health, but very years a significant advance has been observed in some few have incorporated nutrition activities in the local institutes, where a better balance between research health services. and practical programmes has now been achieved, At the national level, three stages of development although there is still need for an increase in practical are customary. A small nutrition unit, attached to measures. the maternal and child health service or other public The functions of a national nutrition institute or department, is organized at the commencement of department have been clearly established and accepted nutrition activities. These activities frequently expand, along general lines.Such functions include: epide- and the second stage is the formation of a larger unit, miological research on the prevalence and nature of which is, however, still closely associated with other deficiency diseases and their association with other departments in the health ministry.The third stage public health problems ;the study, through dietary at present often involves the setting -up of a national surveys, of food consumption and habits in different nutrition institute which, although maintaining some areas; the training of local workers; and the prepara- association with other public health departments, has tion and supervision of practical nutrition programmes a certain autonomy from the administrative and carried out at both national and local levels. technical points of view. In some small countries it is difficult to organize a The pattern of institutes of nutrition varies in national institute. Equipment is expensive and it is different parts of the world.Sometimes the emphasis not easy to find personnel with the requisite scientific is on food analysis.In many countries the amount qualifications.This problem has been solved in of time, work, and consequently money expended on Central America by the creation of an Institute for the thisprocedureisdisproportionatetotheresults five countries of the area: Guatemala, El Salvador, achieved.Differences in the nutritive values of foods Nicaragua, Honduras, and Costa Rica.Panama is in various parts of the world are not so great that a also included by reason of its close association with detailed study of all local foods must be undertaken the Central American countries.This is known as the before any work is carried out in a particular country. Institute of Nutrition of Central America and Panama In many cases, tables of food composition in neigh- (INCAP), the Director of which is also the regional bouring or agriculturally similar countries can, for all adviser in nutrition of the Pan American Sanitary practical purposes, be used in the initiation of nutri- Bureau (WHO Regional Office for the Americas). tion programmes to improve public health.The work The history of the Institute dates from 1946, when of food analysis laboratories will, of course, be of representatives of the above -mentioned countries met value to complement other activities designed to with the Pan American Sanitary Bureau and the improve the food situation of a population but should Kellogg Foundation to found a unique, co- operative not form the sole or main activity. venture to study the nutrition problems of the area, Some national nutrition institutes also tend to con- to work out ways in which the difficulties in question centrate on dietotherapy, which involves the organiza- might be solved and to assist in the application of tion of special services for the dietetic treatment of such solutions. diseases. Over -emphasis on this very limited subject The basic activities of the Institute are financed by may create difficulties in expanding other nutritional equal contributions from the six countries and by programmes.Other institutes frequently emphasize special grants from certain institutions and founda- supplementary feeding programmes for schoolchildren. tions.The INCAP Council, which meets annually, Although this kind of programme is necessary in most has been most successful in promoting harmonious countries, an appropriate balance with other types of relationships among several countries engaged in activity -education, for example -is desirable. nutrition and health programmes.By carrying out In an evaluation of the nutritional services provided fundamental investigations in the field of nutrition, throughout the world, an important feature is the lack by stimulating and guiding work on applied nutrition, of proportion between the time, money and effort and by training large numbers of students from many devoted to research and that devoted to practical parts of the world, INCAP demonstrates the prac- programmes.There has been a great improvement ticability and the tremendous advantages of the in the development of research on nutrition problems, regional approach to common problems. and several centres for investigation have now been Another aspect of the problem is that in many established in each continent.Unfortunately, there countries there are official and non -official agencies has not been a corresponding increase in practical and establishments specifically devoted to the protec- measures designed to improve the general nutritional tion of certain population groups -children especially. conditions of the population.However, in recent These are engaged in useful work and are often sup- THE DISTRIBUTION OF FUNCTIONS IN THE HEALTH SERVICES 51 ported by substantial resources, but they act in- maternal and child health centres at the present time. dependently of each other and of the national and In the first year of life the child generally receives local public health services.More nutrition pro- adequate attention from these centres -at least in grammes could be undertaken and many others some countries -and when he goes to school he again improved if co- ordination of these agencies could only comes under some medical supervision.In the inter- be achieved. vening years, however, he lacks medical care, though To improve health through better nutrition it is it is in this period that children are most exposed to essential to have the participation of other depart- the hazards of malnutrition and infection.In some ments, such as those of agriculture, economics and countries there is a tendency which favours extending education.This point needs to be emphasized because supervision to cover pre -school children.The inclu- the lack of such participation not only delays the sion of public health nutritionists assigned to maternal solution of problems but may also create new ones. and child health centres on a regional basis has been The importance of relating agriculture to nutritional recognized as a valuable contribution to the work of requirements and food policies was first recognized at these centres. an international level by the League of Nations, and Finally, it is important to obtain a better definition at its Assembly in 1935 the phrase " the marriage of of the nutritional activities at the local level, and of Health and Agriculture " was coined.The initiative their priorities, because the best results will be achieved of the League led to the establishment of national when the traditional services of the health centres can nutrition committees in a number of countries.These incorporate nutrition programmes as a routine activity should be composed of authorities in health, nutrition, along well- defined lines of responsibility. economics, and agriculture. The progress of nutrition activities in the world has been severely affected by the shortage of qualified 8.VETERINARY PUBLIC HEALTH personnel, and training has been accepted by the nutri- tion institutes or departments as one of their most Veterinary public health is concerned with the con- urgent tasks.Several schools of nutritionists and trol and eradication of diseases naturally transmissible dietitians are now functioning all over the world, and between animals and man.It undertakes laboratory in addition to the very well -known schools in the and research work in its own sphere and in combina- United States of America, Canada and Europe, similar tion with health and agricultural services.Veterinary schools have been created in other countries in the public health is also concerned with the important last twenty years.In Latin America, Argentina was function of educating and training professional and the first country to have a School of Dietitians, and auxiliary workers.The object of establishing veter- now such schools are to be found in the majority of inary public health units is to improve team -work Latin American countries.The most outstanding in the various joint activities in government administra- example is probably that of Japan, where there are tions; for example, responsibility for food control 102 schools which have trained over 16 000 nutri- varies widely in different countries and at different gov- tionists.1Brazil has also developed training activities ernmental levels within the same country. The depart- on a large scale during recent years. ments of health, food, agriculture, social affairs, etc., As has previously been mentioned, national nutrition may all be concerned with food hygiene.The essential services have been organized in most countries, purpose of food hygiene is to prevent the transmission although much still needs to be done.Activities at of disease to man through food products, especially the local level, however, have not kept pace with and the perishable foods of animal origin (meat, milk and are less effective than national programmes. Practically milk products, fish, poultry and eggs) and to ensure all services in local health centres have some part to that the consumer receives a wholesome and nutritious play in improving the nutrition of the population in product.Itisclear that the supervision of food their area, but in fact these activities do not generally hygiene is a public health function.It has many other form part of a previously defined policy.Two services aspects,especially in connexion with agricultural in the public health centres at the local level- maternal economy.As part of the health service, however, and child health centres and health education- have it must secure close co- operation between the medical undertaken most of the nutrition activities. side and the veterinary. The poor nutritional state of the pre -school child In the hitherto less developed countries there have is one of the most serious problems confronting been rapid advances in the co- ordination of public health services.In this development attention has 1 1956 data been given by many governments to the contribution 52 FIRST REPORT ON THE WORLD HEALTH SITUATION of theveterinaryservice.Most nationalhealth ing clear, at any rate, that veterinary work is beginning departments employ veterinarians to carry out func- to play an increasing part in community development tions relating to food protection, the study and at the rural and village levels.Veterinarians can eradication of diseases transmissible between animals contribute usefully to village health and economic and man, and the organization of research in matters status,bringing together in simple terms animal of common concern to human and animal health. husbandry and hygiene.An approach to rural health In most areas the veterinary service has been closely problems with the assistance of a veterinarian is related to agriculture but there is a trend towards closer more likely to be understood and appreciated in the collaboration with health departments.This integra- less advanced communities than the pioneer work tion can best be carried out, in the first instance, by the of thehealthofficersalone.Thisco- ordination establishment of veterinary public health sections in between the veterinary service and the agricultural national health administrations staffed by trained economy deserves urgent consideration.The com- veterinarians with appropriate personnel. At the inter- bined resources play a part not only in community mediate and local level of public health organization development but also in simple but penetrating health it is not possible to set a universal mould. A great education. A veterinarian can do much to explain deal depends on the co- ordination from the centre. to rural and small town communities the hazards of The national director has to work out a scheme which animal diseases and pest infestation, the danger of will give a service at the various levels of activity. transmission to man and the means of handling Most of the research work will be carried out at situations in advance.This can be done by simple governmental or regional levels, the local areas acting talks to voluntary bodies, including parent- teacher as transmitting centres -especially in the control of associations, rural institutes and dairy associations, on the zoonoses. food handling and particularly the protection of animal At the intermediate level, the problems of integration foods in the course of production.The importance are very similar to those of the national service because of this approach in community development cannot they include research work, food protection and the be overstressed. control of specified transmissible diseases.It may well be that in the more populous areas the main executive functions fall on the province or region, the 9. HEALTH AND THE ENVIRONMENT national activity being directed towards co- ordination and general guidance.It is in the region also that From the very beginning of public health organiza- co- operation is best secured between teaching and tion the subject of environmental sanitation has given research schools, agricultural studies at the university riseto the great majority of government health level, and the major hospitals and medical care regulations.This statement applies to countries in services. all stages of development.In European countries, In the local public health unit the extent of service such as France, Germany, Italy and the United depends on the size of the public health department Kingdom, most of the early laws and regulations and the population of the area to be served.In the referred to some abuse of the citizens' environment larger cities a veterinarian would be a member of -for example, the accumulation of rubbish in public the public health team, which includes medical officers, places, the effects of bad paving and its interference sanitary engineers, public health nurses, and sanita- with traffic, and, in general, the want of cleanliness in rians.In the smaller areas it is seldom feasible to city streets.In addition to these shortcomings, the have a fully trained veterinary officer on the spot, absence of a drainage system raised acute problems but part -time veterinarians can be assigned respon- in getting rid of liquid waste material from houses - sibilities for visiting areas at regular intervals and for as the old Edinburgh city cry of " Gardyloo " 1 dealing with the problems which are of combined bears unpleasant witness -the housewives emptying agricultural and public health importance. their slops out of the window into the street.In In many countries of the world today there is a many of the larger and more populous areas of the lack of qualified veterinarians, and it is often necessary world, at different periods of time, crude environ- to train assistants in techniques and procedures that mental deficiencies have been held responsible for will assist both the health and the agricultural service. the propagation of disease, often with a good deal As in the case of assistant medical and dental officers in of justice, as epidemics of cholera and typhoid have relatively remote areas, short -term training can be demonstrated.Indeed, most of the major epidemic given to veterinary workers to enable them to work under supervision from a major centre.It is becom- 1 From gare de l'eau, pseudo- French for gare l'eau THE DISTRIBUTION OF FUNCTIONS IN THE HEALTH SERVICES 53 diseases which are only now being conquered have pollution, and, to an alarming degree, water of un- been caused directly or indirectly by bad sanitation satisfactory quality is being delivered to homes and or some other grave fault in the environment.Even industries. in the insanitary Middle Ages, the municipal author- A third trend which has been observed in the health ities of many prosperous towns were forced to take services of many countries is a growing interest in measures to rid the area of accumulations of dirt. thewater -bornetransmissionofvirusdiseases. The gradual development of water supplies from During the past few years there have been numerous some common source, such as a reservoir or a river, references in scientific literaturetothis route of served at first only as a partial remedy, because few infection in poliomyelitis and infectioushepatitis, precautions were required or taken against contamina- and the unfortunate massive epidemic of the latter tion by human excreta and the like.As often as disease which occurred in New Delhi in November not, even public water supplies were ill -protected both 1955 has awakened health authorities in all parts of at the source and in their course through badly made the world to the serious nature of the problem.This piping systems; and a large number of wells which epidemic involved some 29 000 cases with about remained in cities became more and more liable to 90 deaths.It was unique in that the water supply direct pollution as housing congestion increased. concerned had been given all the conventional treat- The same process of gradual installation of public ment -that is, coagulation, sedimentation, filtration water supplies and proper drainage in towns at least, and chlorination -, and throughout the course of the has been in operation in many countries which are epidemic it was observed by biological analysis that now in the process of industrialization.When the the steps taken by the engineering authorities were industrial revolution took place in England no system normally sufficient to maintain bacteriological purity. of control of housing or town planning was in exis- This observation was corroborated by the fact that tence.At the height of this period the environmental there was no significant increase in enteric diseases sanitation situation in the growing cities was therefore such as typhoid fever, diarrhoea or dysentery during the actually worse than it had previously been.It was period in which the raw water had been contaminated. not until the great Public Health Act of 1875 that The question may therefore arise whether treatment any co- ordinated system of environmental sanitation which is sufficient to remove bacteriological conta- was introduced and generally enforced.Many of mination is adequate to inactivate the virus of in- the less industrialized countries have not yet reached fectious hepatitis.Serious research is now under the stage of enforcement, and in quite a number of way to devise practical methods to protect the people them only the larger cities and towns have a com- from this type of infection. prehensive system of water supply and drainage. With regard to rural water supplies, it has long been Nevertheless, progress is being made with increasing recognized that in most of the countries of the world speed.During the past three years a number of there is an urgent need to improve the sanitary quality significant trends can be observed in urban water of the water used by village populations.Schemes for supplies.One of theseis the improvement on a this purpose are difficult to carry out, and even a wide scale and the modernization of water treatment moderate improvement of the health of people in works and distribution systems.More efficient filtra- country areas by this means seems to be still far in tion schemes are being put into use in many cities. the future.It is very difficult to assess the minimum One of the adverse trends is the increasing number needs of village people.Wells can be made safe of installations for the storage and treatment of water in a technical respect, but only a thoroughly planned which are being constructed without adequate super- community health programme can educate people vision by the public health agencies.In their eager to use them prudently.However, enough experience desire to improve the quality of public water supplies has accumulated in a few countries to show that some municipalities, particularly in countries where improvement of rural water supplies is practicable, skilled engineering services are not available for health given the understanding help of the local community. purposes, have left the entire business of specifying, In Brazil, for example, the programme for getting designing and constructing waterworks in the hands better water supplies in small rural communities has of commercial firms.In effect, these cities and towns been successful through the discovery of technical are saying to private contractors, " Please build us and administrative methods which can be applied a water purification plant ", without laying down on a wide scale.It is interesting to note the increasing any criteria whatever for the quality or safety of the emphasis which is being laid on the availability of water that is to be supplied.Frequently these plants water in quantity as a public health factor, rather are designed without even proper safeguards against than insistence on its quality.Research in the United 54 FIRST REPORT ON THE WORLD HEALTH SITUATION
States of America, Venezuela and Brazil has pointed urgency, is the pollution of rivers and streams by clearly to a reduction in diarrhoea) diseases when a waste products from factories -wastes from metal really substantial quantity of water is made readily processing, from cyanide and chromium, organic available for maintaining personal cleanliness and a wastes from such industries as pulp and paper pro- clean environment. duction or food -processing.Many of these wastes, The reports from many countries indicate a strong although not actually toxic, make water unpalatable, demand for measures to improve the general environ- in addition to their effect in damaging the amenities mental situation.One striking example of this has of the countryside. been the inclusion of sanitation in programmes of Over and above direct industrial damage an increas- community development, building up from the local ing amount of harm is being done by air pollution, level in rural communities.Most national govern- attributable to industrial gases, fumes and smoke ments recognize the need to carry forward well - and the exhausts from automobiles in crowded areas; integrated programmes of social and economic develop- in the colder zones the use of crude domestic fuel has ment, with general sanitation occupying a prominent a similar effect.The notorious " smogs " of London, place.New techniquesare being triedout:for Los Angeles and the Ruhr are striking examples of this example, the composting of municipal refuse together danger and on occasions have taken a heavy toll of life. with night -soil is being carried out vigorously in several Smoke is slow to clear, but a number of highly indus- Asian countries.Japan has taken the lead in research trialized towns have taken the lead in introducing and development, closely followed by China and the legislation -with beneficent effects.In this connexion Philippines.This method of treating night -soil seems St Louis and Pittsburgh, in the United States of to offer a solution to the age -old conflict between the America, and Manchester, in England, deserve special benefits of conserving the fertilizing value of night -soil mention.There are many manufacturing areas which and the hazards to health and amenity arising from do not use smoke -producing fuel and so have no the use of the raw material.Rapid mechanical problem.It is to be observed that smoke produces composting brings about the generation of tempera- many indirect hazards in addition to its direct attack tures high enough to kill pathogenic bacteria and the on the lungs.Its destructive effect on buildings, the various forms of intestinal parasites. production of dirt in people's homes, and its effects Perhaps the greatest advance that can be observed on clothing are all examples of indirect but serious in environmental sanitationisthe better training damage to health.The problem is likely to become of personnel.Governments are realizing that effective one of great urgency in urban areas which are pro- programmes cannot be instituted or put into effect gressing rapidly, unless preventive measures are taken without specially trained inspectors and operators. in advance. To an increasing extent they are carrying out com- In addition to the more specific conditions men- prehensive programmes on a national scale for training tioned above, over -rapid industrialization without these auxiliary health workers.Schools for sanita- careful planning will inevitably lead to a series of rians and sanitary inspectors or overseers are being other public health risks.Among these are the over- organized and regional courses are offered in many taxing of water and sewerage systems, the danger of parts of the world for training sanitary engineers a breakdown in public services, especially in relation at both undergraduate and post -graduate levels.In to cleansing, food protection, and general environ- these schools and courses the students can receive mental supervision. instruction in their own language and under conditions The rapidly growing industrial towns of the more really comparable with those in their home country. recently developed regions are frequently lacking By means of the establishment of these training inwell- thought -outschemesof townplanning. methodsthenational healthadministrationsare Among the main problems may be listed: becoming more competent to deal with sanitation, even in difficult areas, and are relying more and more (1) The retention of an "old city" of narrow on their own resources. winding streets and densely packed buildings.There The road to better environmental conditions is not is no objection to retaining an " old city " if it has always easy.With the rise of industry, countries are historic associations and buildings of antiquarian being faced with new factors which are now exercising interest or intrinsic beauty. Nevertheless, the city a detrimental effect on sanitary conditions, even in should be part of the improvement scheme and planned areas which have already achieved high standards of with as much care as any other development, especially sanitation.One important new problem, as industrial as regards limiting the number of residential buildings development proceeds with increasing speed and and preventing a crowding -in of new business and THE DISTRIBUTION OF FUNCTIONS IN THE HEALTH SERVICES 55
industrial premises. A great many of the ancient permanent shacks inhabited by " squatters " without centres ought to be preserved with great care, but this rights of possession.The environmental functions is all the more reason for imposing strict conditions of the city health authorities are thus being con- in the interests of both health and history. tinually thwarted and powers which they wish to exer- cise are often enough too little and applied too late. (2) The planned organization of a modern com- The planning of urban growth involves not only mercial and administrative centre, apart from the old the control of housing but also the location of factories. city and yet in an accessible position, is of great In many of the older industrial towns, and unfor- importance.In some cases - particularly in Asia tunately in the new ones also, factories have been and North Africa -the modern city is completely planted without thought of convenience of transport separate from the old.Frequently the old town has from the workers' dwellings. Now and then em- retained its traditional artisan industries, its commer- ployers have built townships to house their own cial activities, such as bazaars, and not infrequently workers and under these conditions the actual plan it is still divided into sharply defined quarters along is usually satisfactory.But it frequently bears little racial or religious lines.A few of the old cities in relation to planning as a whole in the industrial area. the Eastern Mediterranean area have grown to a The result of this is that groups of dwellings may be considerable size without admitting any substantial totally cut off from other residential neighbourhoods modern elements.In other cases -notably in Latin by lines of unplanned factories and perhaps railways America -the modern city and the old are inter- and docks. When cities expand rapidly, the new- mingled, and unfortunately modern expansionis comers may settle in older tenement slums or drift tending to overwhelm and nearly obliterate the ancient into hastily built suburban cottages and temporary landmarks.There are, of course, increasing numbers dwellings.Much depends on the existing buildings, of towns, many of them scattered throughout Africa on whether there is any space at all in the town south of the Sahara, where new industrial mining centres.If the land on the outskirts has to be used and oil- producing centres have sprung up like mush- these cheap townships spring up very commonly on rooms, without any older foundations. pieces of ground that have been left alone precisely (3) When towns grow at great speed, as in England because they were unsuitable for building.These during the 19th century, there are two major threats may consist of half -filled -in swamps, as in certain to health and amenity.The first, which was so districts of Bangkok, steep hillsides, as in the favelas prominent during the European industrial revolution, of Rio de Janeiro, or on low ground subject to flooding, was the building of cheap and shoddy dwellings - as in Baghdad and many flat riverside areas, or on often a long row of cottages or tenements without any kind of waste ground, such as an old refuse dump. any real planning scheme at all.The main object Sometimes the land has been left because of its diffi- of the builder was to cram the largest number of culty of access for drainage and water supply or even buildings into the smallest possible space, without perhaps because it has been held back by owners in regard to the welfare of the tenants.In other count- an anticipation of future commercial or residential ries in many parts of the world slum building of this development.Wherever these dwellings are built, kind has not taken place, although there is frequently the one feature in common in unplanned develop- a gross overcrowding.What happens is that a zone ment is the formlessness often associated with an of huts or shacks springs up on the periphery of the almost complete absence of made -up roads.Some new town.Sometimes, as a result of careful planning, of these areas improve as time goes on and the in- the suburban areas are made up of little villages which dustrial occupations become more permanent.In maintain traditional values and the quality of rural the more economically advanced countries, housing society; but far more frequently this zone looks like controls are extended by enlargement of the city a gold -rush town of the western states of North boundaries or by better regulation of the rural environ- America, consisting of formless shanties and without mental by -laws.Even at best, however, there is a any kind of physical or social organization.Some- lack of community in these dwelling areas which makes times these shanty towns consist of caravans and other them always appear as temporary and makeshift, and movable dwellings and are often outside the adminis- as time goes on they become increasingly difficult to trative boundary of a city, which has reasonable improve at any reasonable cost. powers of enforcement of health regulations.Many These rapidly industrialized towns spread more of them are so placed that only a weak rural authority freely where the surrounding area is sparsely populated, is responsible for providing sanitation or planning, as in many parts of Africa and Latin America, or and often enough the movable dwellings become semi- where desert or uninhabited land is found at the gates 56 FIRST REPORT ON THE WORLD HEALTH SITUATION
of the city.In densely populated parts of Asia, workers and housing managers to help those who however, and, since the war, in a number of countries live in slums to appreciate and take advantage of the which have suffered from mass immigration, the new living standards, and at the same time there must prodigious movement of the people inwards -and be a move towards higher wages, so that the economical particularly waves of refugees -has forced the creation rents can be paid. of shanty towns.More commonly, the growth of How arethese environmental functionstobe these disordered dwellings is limited by the fact that distributed in the health services ? One or two useful land is intensively cultivated right up to the edge of answers to this difficult question are gradually emerging the city and is thus too valuable for immigrant occupa- as a result of studies made on the spot.The first, tion.This difficulty does not prevent rapid city and in many respects the most important, is that growth: it simply means extreme overcrowding, both in environmental services grow best when they are the older parts of the city -the market places and the firmly rooted in community life.In the rural areas streets -and in the improvised slums that have sprung and villages they ought to be an essential part of the up on the few odd pieces of vacant land, such as river- community programme, and the enthusiasm of the banks and swamps.It seems that the housing situa- local residents is the only real guarantee of continuing tion in many cities, especially in Asia, has actually success.The larger towns and cities seem at first deteriorated in recent years because new building sight to present an entirely different problem; but has not kept up with the natural increase of the urban on closer examination it is found that they have a population, let alone the flood of immigrants.The good deal in common with rural areas from many increasing demand for housing is prominent also in aspects.Cities, and particularly new towns and the lower middle class, and among better paid workers extensions of the old, are made up of neighbourhoods. and clerical employees.These groups have generally It is true that the worst of the peripheral shack towns been housed in the older parts of cities to which time are notoriously lacking in any communal spirit, but has brought deterioration -along with increasing surely this very fact points to one solution: that the rents.Not infrequently the actual accomodation avail- health services should make every effort to create able to them is shrinking because of demolitions and neighbourhoods in these unorganized areas, and so the inroads of shops and upper- income apartment link families together with the bonds of common houses.At the same time these groups have them- interest.Regarded as a whole, the achievement of selves felt a great need for better standards of housing housing, planning and other environmental tasks seem and especially for relief from overcrowding.The to be beyond the wit and the purse of a health service. city administrations everywhere are making great Yet if the areas are systematically divided for these efforts to provide more houses.The emphasis must purposes, gradual local progress seems to be within lie on low -cost dwellings and encouragement by sub- the grasp of people who have a common interest in sidy of private construction, either on an individual making good.When new estates and new towns are basis or through housing societies.Attempts have constructed today, one of the first functions of the been made in some territories to prevent the inflow authorities for health and social services is to use of migrants unless they have steady employment. existing material in order to support the formation These measures have seldom been effective.The of real communities.This cannot be done without whole problem today points to the need for further financial expenditure, but a governmental or regional research in housing and town planning.One of the subsidy to a good local enterprise seldom drifts away most promising advances in recent years, which will in heavy administrative costs, because the people be further explored,istheconstruction of self - themselves have a stake in success. sufficient new towns with a complete decentraliza- The second answer is that the public health service tion of industry.The overwhelming advantage of the as such cannot be set moving in isolation; it must new town is that the worker both lives and has his be associated with other environmental activities such employment in the same place, thereby saving the as road -making, land drainage (especially in the neigh- money and time spent on travel. bourhood of towns), as well as co- operation between Unfortunately the housing question goes far beyond neighbours in the planning of open spaces, schools, construction alone.It is not merely a question of libraries, and other public services.Water supplies building dwellings.As industrial development takes and the disposal of waste materials cannot be dealt place, the workers and their families feel the need for with satisfactorily except in harmony with other more space, better sanitation, and more amenities in developments.From these simple illustrations it is and around their dwellings.If a housing programme not difficult to see the need, at all levels of govern- is to be effective, it requires intensive efforts by social ment, to create authorities for the promotion of com- THE DISTRIBUTION OF FUNCTIONS IN THE HEALTH SERVICES 57 munity enterprises, with sufficient funds attheir search work, has made this technique indispensable. disposal for smooth, steady progress. The replies from many of the countries involved The third answer, which is implicit in the first two, show an encouraging desire to proceed with all speed is that no permanent advance can be expected in the on the road to complete eradication of malaria. absence of an educated and understanding community Some failures have occurred, it is true, but these have -educated, that is, in the benefits of a sound, practical generally been associated with administrative defi- health programme which is, so to speak, well within ciencies or faults in the preparatory work, and not the range of their everyday vision. with flaws in technique. It is essential that the machine should run smoothly. A mere glance at the situation in the world as a whole quickly disperses any mists 10. THE CONTROL OF COMMUNICABLE of easy optimism.The problem is of colossal di- DISEASE mensions, especially in Africa, where the particular epidemiological problems make much research essen- In general terms the control by mass measures tial before effective eradication can be aimed at. of an infestation or a widespread communicable Yet this knowledge ought not to deter governments disease has a salutary effect on a country.Many of from a forward strategy.Perhaps some of them feel its people, especially where a campaign touches rural that an all out antimalaria campaign would so reduce areas, are brought into contact with the health ser- the funds and staff available for other health purposes vices for the first time.By this means they begin that the want of balance would be disastrous.This to appreciate what is being done for them, and in fear is understandable, and it is no doubt very difficult the course of time to press for extension of the benefits. to determine where the true priorities lie; but one This is the moment when the local inhabitants should must remember that the toll of malaria in sickness be made partners in health work on a voluntary and a dreary sub -health is exceptionally high, and that basis, however little their contribution may be in the much of the cost of a progressive eradication pro- early stages.It is a fact that progress is hard to come gramme might be recouped in other ways. A marked by unless the people are with the experts -unless improvement in health and well -being has a stimulating each scheme is brought into their understanding and effect on the economy and working capacity of a wins their goodwill.It has been shown, for example, people. that in the wake of campaigns against yaws and le- The system of control by case -finding and treatment prosy, community effort has established rural health has been applied successfully to yaws and endemic centres.The combined attack on several infections syphilis.One practical result of field studies was the has the effect of strengthening the service at the local observation that case -finding alone was not sufficient level.At the same time it makes for economy in and that contacts must be treated, because they staff and transport, and, under proper supervision, it provide a reservoir of infection which, if allowed to creates an efficient administrative unit that becomes a remain, would vitiate the results of a mass campaign model for a whole district.In a number of countries of eradication.Cases have to be searched out method- pilot projects have been set up; the intention of such ically, for missed cases and missed contacts renew projectsistodefine local epidemiology and the the spread of infection.Long- acting penicillin pre- methods of application that are locally indicated. parations have proved their value, although limitations Once the most economical methods are established, may be imposed by sensitivity reactions.Constant application on a wider scale is advocated.The most watch has been kept for the development of resistance, successful projects are those which pass out of the but until now none has been noted.Governments demonstration stage and become permanent, decen- begin to realize that the price of safety iseternal tralized units of a national health service. vigilance -and continuing experiment. Many governments have now accepted the policy In many parts of the world smallpox is still a menace, of malaria eradication which depends on the syste- although its control by vaccination has been recognized matic application of residual insecticides.It has been for several generations.(See fig.3.)One of the demonstrated that if transmission is interrupted for practical reasons for the failure to control the disease is a sufficient length of time, by breaking the cycle at that ordinary vaccine lymph rapidly loses its potency the level of the vector over a wide enough area, the when exposed to the high temperatures of the tropics. infection dies out.In this way costly measures of Dried lymph with increased stability has proved control can be replaced by much cheaper routine satisfactory in certain countries and disappointing supervision.The development of resistance to in- in others, but a new method of preparation which secticides by the vector, demonstrated in recent re- gives much greater resistance to heat has now been 58 FIRST REPORT ON THE WORLD HEALTH SITUATION
FIG. 3.NOTIFICATION OF SMALLPDX CASES, BY CONTINENTS, 1948 -57
500000 500 000
400000 400 000
Americas Africa
IIIIIIIIIIIIII 300 000 300 000
200 000 200000
134 000
100 000 100000 IIVIIIIIIIIII011! 1110111101111111 IIIIIIIIIIIIIIIIIII
mmmunnuu
o 1948 1949 1950 1951 1952 1953 1954 1955 1956 1957
e Excl. Union Of Soviet Socialist Republics end Continental Chino exo eses devised.However, effective control depends on the BCG is becoming more and more widely applied, and existence of adequate health services to apply syste- there is little doubt that it will drain the reservoir of matic vaccination, and these are lacking in some infection in a population; but it is not sufficient to countries. deal with persons already infected and so bring the Most of the other communicable diseases have not total disease under control.The strategy against yet been brought within sight of extermination, but tuberculosis must combine BCG campaigns with a good progress has been made towards the control full programme of case -finding and treatment, aimed of some of them -notably poliomyelitis.In this at reducing the sources of infection in a community. disease the preparation of an inactivated virus vaccine In recent years the use of drugs in the ambulant care has made it possible to prevent to a large extent the of the tuberculous has come into prominence, and paralyticcomplicationsofinfection.Progressive indeed this may prove to be the only feasible means of research over the years will, however, be needed in control if relatively cheap non -toxic substances can epidemiological studies and in selecting the best type be produced.At present, various trials are being of vaccine and determining the optimum method of made, especially with Isoniazid either alone or in use.Itisone of the few serious communicable combination with PAS. diseases with a rising incidence, and it is tending to The control of trachoma has been referred to by attack the higher age -groups, in which paralysis is many governments.Local treatment by antibiotics, often more severe.Unfortunately there are too many employing repeated applications over a long period, countries which lack staff and organization equal to although having inherent difficulties as a mass measure, the task of producing this vaccine and applying it has proved to be possible and effective.Recent successfully.It is often difficult to persuade a people studies in the field have shown that in certain epi- to accept preventive measures in advance of a sea- demiological circumstances both the frequency and sonal outbreak, and this is precisely what is necessary the length of treatment can be reduced to reasonable in a campaign against poliomyelitis. proportions.Large campaigns became feasible by In tuberculosis the fall in the death rate continues, training school- teachers and others to carry out the at least in those areas where reliable statistics are work under supervision.Trachoma control should available.But itisstill a serious world problem. only be started after local epidemiological studies FIRST REPORT ON THE WORLD HEALTH SITUATION 59
have been carried out to define the role of the asso- One of the most interesting field studies of recent ciated conjunctivitis and bacterial infections.Further years has been the investigation of the natural endemic laboratory and field research on simpler techniques foci of the zoonoses -the study of how the agent remains essential. that causes the disease persists in nature and the route One of the diseases in which the closest collaboration by which it is likely to be transmitted to man.The between public health and veterinary medicine is existence of these foci attracted the attention of indispensableisrabies.With that team -work in scientists in the Union of Soviet Socialist Republics action the prospects of ultimate control are consider- when encephalitis was diagnosed among people who ably improved.The first approach is to reduce the went out in spring and early summer to semi -desert chances of human infection by immunizing and con- areas in the far -eastern regions of the Union.The trolling domestic animals in contact with man - small, scattered population made man -to -man trans- especially dogs.The second approach is towards mission very unlikely, and a cause of infection was better methods of treatment, both local and systemic, eventually traced to animals inhabiting the locality. for wounds caused by the bites of animals suspected Similar investigations have been carried out success- of being rabid.It has been shown that the use of fully in Poland and Czechoslovakia.These findings hyper- immune serum has a striking effect in reducing might be briefly summarized by saying that natural mortality after severe exposure, when vaccine alone endemic foci of the zoonoses may remain undetected may prove deficient. or dormant for indefinite periods; indeed, they may The traditional communicable diseases of child- remain in this state so long as human beings do not hood- scarlet fever, diphtheria, measles, and whooping - have access to them.Nevertheless, they are a poten- cough -have declined considerably as causes of death tial danger, and their existence and position should be in most European and North American countries. worked out in advance. Fortunately, there are some However, they are still -particularly the three latter useful clues : these foci have definite ecological pecu- diseases -a health problem in many other parts of liaritiesaccording toplace,climate, presence or the world.In the temperate zones, diphtheria pre- absenceof vegetation,and otherenvironmental valence and mortality have declined as vaccination factors.Such clues indicate whether certain diseases has become more widely applied. are likely to exist in the area under study.This type Thanks to improved sanitation and to improved of field investigation, which has become known as international quarantine control, " pestilential " dis- " landscape epidemiology ", is valuable in suggesting eases have in recent years lost much of their wonted potential risks, especially in unknown territories where importance, although they still constitute a potential man is about to settle for the first time.As an danger. example, the presence of leishmaniasis, or Oriental Plague, albeit widespread among wild rodents in sore, might be suspected in desert areas inhabited many areas in the interior of Africa, America, and by burrowing rodents.In tropical Africa, a region Asia, has less and less access to domestic rodents and of bush country with big game, or with river banks man.Only 514 cases of plague were recorded in 1957. surrounded by thick vegetation, would lead one to Cholera is now practically confined to India and Pak- be wary of, the presence of trypanosomiasis.The istan, 66 000 cases being reported in 1956. (See fig. 4.) essential point is to anticipate the epidemic possibilities Yellow fever, owing to Aëdes aegypti control in of such areas, so that they can be avoided -or, Central and South America and the extensive vaccina- failing this, so that human beings can be protected tion campaigns carried out in both tropical America against infection.In some instances the affected and Africa, has practically ceased to be a human territory may be freed from danger by exterminating disease, only 25 cases being reported in the Americas thereservoir hosts and vectors.Inothers,this and only half -a -dozen in Africa in 1956.Epizootics method may be too time -consuming and difficult, in the former region, sweeping the tropical forest as owing to the nature of the foci.It might then be far north as Guatemala and British Honduras, prove feasible to introduce mass vaccination of the people that control measures cannot be safely relaxed. at risk. Typhus fever remains prevalent in all continents, There are a number of good examples of the in- but the number of recorded cases does not exceed a few fluence of these concepts on the present -day public thousand and is rapidly dwindling.(See fig. 5.) health practice in the USSR 1.One of the most Relapsing fever is practically confined to Africa, striking was the study of the spread of tularaemia by Western Asia, and the Iberian Peninsula.There were less than 5000 cases reported in 1956, half of 1 See: MEYER, K. F. (1957), Some observations on infective them in Ethiopia. diseases in Russia.Amer. J. publ. Hlth, 47, 1083 60 FIRST REPORT ON THE WORLD HEALTH SITUATION
FIG. 4. REDUCTION OF CHOLERA PREVALENCE, 1948 -57
- -A,.=- =_ -_ _=
CNANESNU/------C H I N A MUCMANg F ANg
. 4
PAKISTAN ::;//j/./::`:i':i:
+M1''`::`:f:'.::`/ d __ __ ,i.C ., BURMA LAOS
CHOLERA + cENTRAL t''_- PROV. : E. PA_KISTIN 1948 and 1957 _____ ji.I
,.`:.`f orro Repdceses. - __:^,<;.. __--_-- THAILAND A --"k;- --_ A ....VIéTNAM--- 1 /IA'' 2.25 =:t:.,:>:}j/. 4 .`'' ` Rares per 100000 aowlarion INDIA:- -___ c d 27. 40 --- E
I 1 6.10 7/ 45-90 --_ 1 -_ -19Y0 r 12-25 ® 100-140
INDIA AND PAKISTAN REPORTED CASES,'1 948.1957
250000 % % : .,.., :%/%L % .// % % %
150000 ---jj!/j/= I00000% SDDDDj//% I%%/// 1948 THE DISTRIBUTION OF FUNCTIONS IN THE HEALTH SERVICES 61 means of infected water -voles and other rodents. laboratory and field investigation and thus provide the The essential mode of infection was the inhalation answers needed to promote simpler and more effective of dust stirred up during the use of straw that had been control methods. contaminated by rodents.The drinking of water fouled by the carcasses of water -voles also caused many attacks.Prophylactic measures are concen- 11.CHRONIC AND DEGENERATIVE DISORDERS trated on the mass destruction of rodents, the protec- AND ACING tion of food supplies and water sources, and the sub- stitution of pine and fir needles for straw bedding. The reports submitted by a large number of countries Unfortunately, the arthropod vectors form a chain make it clear that in the past the most urgent problem of infection from one type of rodent to another, confronting the health services has been the long - and this chain cannot be broken by eliminating a drawn -out battle against the graver communicable limited group of rodents.This difficulty has led diseases.In most of these countries the war will to the development of active immunization with have to continue for many years to come, especially living attenuated strainsof Pasteurellatularensis, the campaign against the major endemic and epidemic which affords a strong resistance to subsequent in- infections.Up to the present less attention has been fection.The system of vaccination is similar to the devoted to a group of disorders which are more smallpox technique, and the reaction follows on the insidious in their attack and more prolonged in their fourth and fifth day with vesicle formation changing course.The dividing line is not very sharp, because to scar. some of the acute communicable diseases tend to In many countries the discovery of new wild rodent slip down into chronic conditions and to give rise to species has shown these animals to be the responsible increasing disabilities.Many of these conditions are sourcesof theplaguebacillusininter -epidemic not in the ordinary sense fatal, but they shorten useful periods. life and often cause a great deal of suffering and Extensive advances have been made in our know- disablement.Unlike the diseases which originally ledge of virus diseases.After it became easier to cause them, they are not, of course, transmissible isolate and identify viruses through the tissue culture from patient to patient. techniques, intensive research led to the discovery The chronic diseases in general are so called because of many new viruses and better knowledge about they tend to affect their victims for long periods, the cause of many unknown fevers.Well -planned either continuously or intermittently.They may make international observation services, through the network their first appearance at any age, especially if they of WHO Influenza Centres, have led to rapid reporting are due to infection, but they join forces with the of new variations of the influenza virus and contributed degenerative lesions as the years pass on towards to timely production of vaccines containing the new middle and old age. We therefore include among strain. the chronic diseases the following groups, by way For certain diseases, such as bilharziasis, incidence of illustration rather than catalogue : israpidly on the increase throughout the world, (1) The disabling sequelae of certain acute in- owing to newly created irrigation schemes established fections such as poliomyelitis, cerebrospinal menin- for the economic and social development of countries. gitis, and some of the common infections of childhood. Although under special local circumstances it might be possible greatly to reduce the incidence of bil- (2) Non -communicabledisordersarising,for harziasis through control of the snail intermediate example, from injury at birth, congenital deformity, hosts by means of molluscicide application, effective accidental injuries and the like, but excluding mental control of this disease needs further field research deficiency and disorder unless accompanied by a on the intermediate host -parasite relationship, the disabling physical condition -as in many cases of application of engineering methods to prevent its cerebral palsy. spread, laboratory work to find a cheap molluscicide (3) The conditions described -for want of a better with a more residual effect, and an improved drug name -as " the chronic degenerative diseases ". These suitable for use in mass treatment campaigns. include mainly, although not exclusively, the rheumatic All these campaigns against communicable disease, disorders of a chronic type, cardiovascular diseases - and the field studies under way, reveal many gaps in especially those associated with atheroma -, malignant our knowledge.The research necessary to fill these new growth, and a variety of long -term neurological gaps has to be outlined.Intensive international co- affections.The chronic respiratory diseases such as ordination of research makes it possible to combine chronic bronchitis, asthma, emphysema, and bron- 62 FIRST REPORT ON THE WORLD HEALTH SITUATION chiectasis might be classified in the same group, as a Their age- incidence and distribution offer valuable matter of convenience. clues, and increasing knowledge of these factors is It has been suggested that communicable diseases leading us towards a better understanding of the under- such as poliomyelitis ought to be divided into an lying causes.In this respect international collabora- acute, infective phase and a long -term non -infective tion is urgently needed. period, if paralysis supervenes.There is much to be Our ignorance of the causes of many of the de- said for making this distinction,as the form of generative conditions should not be taken to indicate medical and social care is entirely different for the that the picture is entirely dark.In point of fact, the two phases.The same principle might well apply sufferers from most of these diseases have found to a slowly progressive lesion of the nervous system relief, through modern medicine, from a great deal of following upon a disease such as meningitis or ence- pain and discomfort; and, if our existing knowledge phalitis of viral origin; it would also apply to the early is applied widely in practice, much can now be done and late stages of trachoma.From the point of view to arrest the progress of the disease itself and to of distribution of functions within the medical services prevent the onset of distressing complications.By of a country this division according to the type of this means life can be prolonged and disability reduced çare and treatment required would be the logical by early diagnosis and prompt, adequate treatment. method. The possibilities of active care through the use of Even the most imperfect returns from countries physiotherapy have not yet been fully appreciated, indicate that all these long -term disorders are present except, perhaps, after accidental injuries.The value to a greater or less extent throughout the world; of rehabilitation in the chronic diseasesisoften but their importance in kind and number varies from remarkable, and even bedridden cripples have been country to country and from region to region.Their brought back into active life by careful attention to incidence is obviously affected by climate and geo- method and management.In all probability the cost graphical conditions in some cases, and by social of comprehensive rehabilitation is one of the main and economic statusinothers.The speed and obstacles to its more extensive use among the lower efficiency of treatment during the acute stage of income groups, but the results in the restoration to attack may have a profound influence on the extent useful life are striking and severity of the ultimate disability.In countries The reports from many countries indicate that a which have gone far towards the control of the major great deal of attention is now being paid to the early acute communicable diseases, the chronic disorders detection of chronic disease, particularly before symp- -especially those affecting the older age- groups- toms arise.Periodic health examinations and mass become relatively important in the record of both screening procedures are now being used for this sickness and death.This is of course largely due to purpose in a number of countries.That such case - the fact that, as countries advance towards skilled finding procedures have not been more widely adopted prevention and the effective control of the great up to the present time is largely due to the hight cost epidemic scourges of man, their citizens live longer involved and to the insufficiency of staff and equipment and are thus brought within the range of the de- to deal with diagnosis and therapy.As yet a great generative disorders. many people have not been educated to an appreciation Unfortunately, the underlying causes of many of of the need for routine examination or to any under- the chronic degenerative diseases are not yet fully standing of its purpose in saving life and health. known, so that primary prevention -that is, averting In some cases also, the medical profession itself has the onset of the condition -is beyond the compass been slow to develop preventive measures of this of medical science.In a limited number of instances, kind. however, wherethecausativeagents have been Until comparatively recently it has not been easy ascertained, it is possible to take preventive measures. to attract the interest of medical students and practi- This applies to some forms of rheumatism and certain tioners in the more chronic conditions, partly because types of occupational cancer; and recent progress in in the past the status of the patients in the so- called basic studies of the blood and circulation has gone " chronic " wards of hospitals or special institutions some way towards clearing obscurities in the pathology has been regarded as inferior and lacking in dramatic of the cardiovascular system.In a similar way excitement.In consequence, active medical care ten- nutritional research has shown promising lines of ded to be concentrated on acutely ill patients, particular- investigation.At the present time a great deal can ly those who could be treated by surgical methods. be learnt through careful studies, in one country and It is only in the last two decades that physician and another, of the epidemiology of the chronic diseases. student have begun to appreciate that much can be THE DISTRIBUTION OF FUNCTIONS IN THE HEALTH SERVICES 63 done to restore the well -being and good functional Aging activity of the majority of those who suffer from the chronic degenerative diseases, even of those who have The tale of chronic disease would not be complete been struck down by cerebral haemorrhage or throm- without some reference to the more or less normal bosis.In addition, a considerable number of persons physiological degenerative changes that accompany suffering from neurological diseases that had hitherto old age.The aging of populations presents a new been regarded ashopelessly incurable have now challenge to the advancing countries, in both social acquired new hope of activity and self -help. and medical spheres. There are also obvious economic One must recognize that medical education has problems which have to be faced as the expectation not yet been adapted to the changing pattern into of life at birth increases, but the more urgent questions which the care of long -term illness has been fitted. are connected with mental and physical well -being Some modification of the undergraduate curriculum as age advances.Many of the aged, even in advanced will no doubt be necessary, and steps are already being communities, suffer from poverty, loneliness and the taken in some medical schools with this end in view. unhappiness that goes with it, and a slowly progressive The value of teaching is enhanced when the student infirmity which lies just outside the boundary of is brought into clinical contact with a person suffering positive illness requiring medical care.Admissions from an illness of long duration in the care of a to hospital have increased, and mental institutions physician who takes a personal interest in the social are generally overcrowded; yet it has been found in and environmental situation of his patient. practice that many of the elderly sick derive benefit In the field of research into the etiology and patho- both physically and mentally if they are cared for genesis of the chronic group of diseases a great deal at home or in homely surroundings. has been done in recent years.Fundamental research The first step forward in the effective care of the has made great progress, notably in the study of the aged is to find out the size of the problem. The plan- cardiovascular system.Valuable contributions have ning of medical and social care, in hospital or at home, recently been made to our knowledge of the blood depends on securing accurate data on the number of and circulation and of the root causes of coronary aged people in any community, in terms of sex and infarction.Nutritional investigations have brought us age -group, and the situation in relation to domestic, nearer to an understanding of the relation of diet nursing, and other assistance.With the extension of to atheroma.Basic studies in genetics have already urban conditions in countries on the threshold of opened pathways into the hidden etiology of cancer, industrial development the old family ties tend to and a considerable amount of knowledge has been loosen: the young move towards the cities in search accumulated on the effects of certain irritant chemical of employment, while the old remain at home in rural substances. areas -or, if they enter town life, the pace of industry Lessons of immense practical value have been is too great for them and they fall out of the race. learnt in the study of functional restoration.The In either case the aging are not prepared for old age. skills of orthopaedics have been brought into the There is an urgent need for the investigation, in range of long -term illness, and modern physiotherapy different kinds of population and environment, of is an indispensable adjunct to the restoration of the basic problems of aging.Little justification has function.Nevertheless, it is of the utmost moment been shown for the view that this growing problem is to bring into focus the benefits conferred by the pro- due to a decline in family affection and a disintegration motion of mental hygiene. A large part of the success of family life.There is, however, a marked increase of of the restorative process depends primarily on the isolation among the single and the widowed who attitude of the patient, and one of the functions of have no children.In the United Kingdom, two -thirds psychiatric careisto adjust the patient's outlook of all hospital beds occupied by persons over 65 years towards confidence in the treatment adopted and the of age are taken up by the single, widowed, and di- firm conviction that the precious boon of health is vorced -and the isolation is most frequently due to within reach.Psychotherapy holds an important bereavement.It is usually aggravated by the inexor- place in functional restoration. able progress of physical and mental infirmity and On thepreventiveside,useful epidemiological actual illness, or by defects like failing sight and data have now been obtained on the distribution of hearing. the chronic respiratory diseases and their relation to The application of public health services to the climate, humidity, and occupational factors.The problems of the aged demands serious and immediate whole range of long -term disorders is being systema- consideration.Two main linesof action suggest tically explored, in both basic and field investigations. themselves.The firstisto bear in mind that we 64 FIRST REPORT ON THE WORLD HEALTH SITUATION cannot affort to waste the talents and the working health promotion, with full arrangements for home capacity of the elderly, and every effort should be care, including, where necessary, domestic and nursing made to find work suitable for their strength -work help and the skilled services of the general practitioner. which is based upon positive capacities rather than In the recent past there has undoubtedly been some on the negative estimates of disability.By this means measure of devaluation of the status and usefulness of loneliness would be minimized and the years would the aged.Much can be done by community services pass with renewed vigour and interest until the end. to redress the balance and to restore this group to The second line of action should be to apply to the its rightful place in the human family." Old age hath aged all practical ways and means of prevention and yet his honour and his toil. " CHAPTER 5
INSTITUTIONS AND FIELD ESTABLISHMENTS
1.NATIONAL HEALTH INSTITUTES, countries, public health laboratories are also engaged INCLUDING PUBLIC HEALTH LABORATORIES inthemanufactureof biologicalproductsand carry out biological standardization.In many well - One of the greatest services that a country can render organized and well- equipped national public health to the advancement of science is through the establish- laboratories, considerable research and field inves- ment of institutes and research laboratories.At one tigationof public health importance have been time the scope of such organizations was restricted, accomplished. perhaps to the study of a single disease like malaria The institutes of hygiene belong to the second cate- or tuberculosis or to the pursuit of a limited range of gory of institution, which performs both research and studies in one of the basic sciences.In recent years teaching functions.The development of this type of the needs of specific research have not been forgotten, institution was stimulated by the Rockefeller Founda- but there has been a healthy tendency in many count- tion at the beginning of this century with the founding ries to broaden the research field to take in a much of the Rockefeller Institute in New York. When wider group of subjects related to man in his environ- health services were being organized on an inter- ment, such as housing, social conditions, mental health, national scale it was soon realized that the most and a greatly enlarged concept of epidemiology. serious hindrance to progress was the lack of trained Institutes may be established by the State, or by men and women.The idea of setting up an institute private beneficence, or by a combination of the two; which combined teaching and research was realized and in this connexion one should not forget the great by the building of the School of Hygiene and Public services given by industrial concerns, especially the Health at Johns Hopkins University, Baltimore.As manufacturers of pharmaceutical products. a consequence of the success of this venture, the former Institutions in which both laboratory and research International Health Division of theRockefeller work in the field of health are being carried out can Foundation conceived the bold idea of setting up generally be grouped into three main categories.The institutes in many parts of the world.The object first group of institutions established to meet the needs was to create centres from which both teaching and in public health work may be identified as public research would radiate, and by this means to help health laboratories.This is the most common type governments to build their local health services on a of institution to be found in many countries, varying more co- ordinated plan.Some schools and institutes from a single -purpose or simple diagnostic laboratory were founded and others were supported or extended to a most comprehensive public health laboratory by subsidies.Among the organizations so created covering chemical, microbiological and entomolo- are those at Ankara, Athens, Belgrade, Bucarest, gical studies.Such laboratories in general carry out Budapest,Calcutta,Cluj,Copenhagen,London, routine examinations for both diagnostic and public Madrid, Manila, Oslo, Prague, Rome, Sao Paulo, health purposes and are operating under national, Sofia and Zagreb.The effectiveness of the scheme regional or local health authorities.In practically was enhanced by the organization of a world -wide all countries or territories where there is a modern system of fellowships so that these new schools could public health service, some form of public health stimulate and reinforce one another and bring about laboratoryserviceexists.In many countries,a an interchange of experience and thought between system of decentralizedpublic health laboratory the best brains in the subject of hygiene and public service has been set up with a central laboratory in health.The fellowship system has proved to be one the capital city as the germinating centre, which of the most beneficent influences in the establishment extends the services to regions and rural districts of good relations between student and teacher and through a network of branch laboratories to assist between one student and another, irrespective of the work of the local health services.In a few nationality and race. - 65 - 66 FIRST REPORT ON THE WORLD HEALTH SITUATION
At this point there arose a historically interesting In France and countries or territories under French differenceof outlook, which had a considerable influence or administration, Pasteur Institutes have influence on the policy of schools and institutes of been extensively established.They serve in most public health.Hitherto,the idea had been that instances as public health laboratories, but in many medical knowledge and discovery had far outstripped countries they function as researqh institutions carrying its application to the world of man - and indeed few out programmes of public health importance. would deny the truth of this at the present time. The third group of health institutions deals with But a generation ago the idea had the effect of con- public health problems, such as nutrition, industrial centrating financial assistance on the application of or occupational health, mental health, and the organi- discovery in the field - the practical task of finding zation of public health services.For example, the means of overcoming diseases, once the cause and Institute of Nutrition for Central America and Panama, method of transmission had been shown.At this in Guatemala, was recently organized by the govern- time, however, a number of scientists who had been ments of the Central American countries to carry trained in the more strict laboratory disciplines felt out a joint nutritional research programme.The that application was not enough.The search for Institute of Occupational Health in Helsinki and the new knowledge was implicit in the application of Institute of Industrial Medicine in Lima are other existing discoveries, for every advance in field work examples of this type, where the institutes not only exposed fresh gaps in the knowledge essential to carry out research but also render services and provide successful control.From that time onwards increas- training in their respective fields.The Netherlands ing emphasis was laid upon pure laboratory research, Institute of Preventive Medicine in Leiden has under- both in the Rockefeller Institute in New York and taken research in occupational health, maternal and in the new institutes as they came into operation child health, mental hygiene and experimental patho- throughout the world. logy and has made valuable contributions to these The national institutes of public health or hygiene subjects.This type of health institutionisalso in Poland and Yugoslavia made valuable contributions represented by the State Institute of Rural Occupa- in the development of rural health units in their res- tional Medicine and Rural Hygiene in Lublin, Poland, pective countries.In Yugoslavia, the pioneer work and the National Institute of Mental Health in Tokyo. of associating health service with the economic and The Institute of Public Health Administration and social development in rural areas was first initiated History of Medicine in Moscow is another example in the early 1930's at the Institute of Hygiene in of the type of health institution recently developed Zagreb. to meet the needs of public health services.The Many of these institutes or schools are still func- main purpose of such an institution is to transform tioning well.They are fully equipped with laboratory the available knowledge in medical sciences into facilities and field investigation units to carry out practical measures for the health protection and pro- epidemiological study and research, in addition to motion of the population, and to tie theory and practice the educational function.For countries where public together in public health work.As an example of health work has not been fully developed as a branch the type of work that the Institute has done, it may be of medical sciences, an institution of this nature will of interest to mention the experiment made on the definitely promote the scientific aspects of public organization of local health services in the Union of health services and help to establish the public health Soviet Socialist Republics.The local health services profession on more solid ground. in a community were composed of three units - i.e., The system of national institutes of health and a community hospital, a sanitary and epidemiological national institutes for medical research in the United station, and a local health bureau.The experiment, States of America and in Great Britain are a relatively initiated in 1956, was to demonstrate in several local more recent development,carryingoutresearch communities a system of integrating all the three functions in both clinical and public health fields. units into one administration under the direction of a The series of national institutes operating under the medical officer assigned to that area.The experiment Department of Health, Education and Welfare in the took about one and a half years in working out the United States of America have specific research pro- details of integration and in organizing the adminis- grammes in cancer, heart diseases, mental health, trative unit to embody the three aspects.This work arthritis and metabolic diseases, neurological diseases, has been carried out in an atmosphere of close co- allergy and infectious diseases, dental health and operation between local medical officers and research blindness.The 1956 budget for all these research officers.It was finally demonstrated that the in- institutes amounted to US $ 97 823 000. tegration could be accomplished, and one adminis- INSTITUTIONS AND FIELD ESTABLISHMENTS 67 trative unit was successfully organized.Based upon ordinary range of voluntary effort.For practical thisfield demonstration, conferences of the local purposes this included the treatment of the major health officers were held to discuss the integration communicable diseases, the care of the aged sick and process, and recommendations were then made to the of persons suffering from mental defect or disorder to Ministry of Health to extend the plan throughout the an extent requiring public care, and general provision entire country. for the destitute.These last comprised a miscella- neous group, such as neglected children, deserted mothers and families, the unmarried mother in need 2.HOSPITALS, OUT -PATIENT DEPARTMENTS, of special care, and the aged sick for whom home care HEALTH CENTRES, RURAL HEALTH UNITS, ETC. was barred on social grounds. Voluntary effort was principally concerned with Historically speaking,itisprobable thatout- providing for the care and treatment of those suffering patient medical care is much older than hospitals. from acute illness, medical or surgical.Sickness in The treatment of the sick has been undertaken in its active stages is dramatic and has a much greater temples from remote antiquity, and the bringing of appeal to the charitable than chronic illness or even the sick to a healer in the market -place has in some old age.Urgent illness and accidents have always territories survived tothis day.The Aesculapiae won sympathy and practicalhelp.The kind of represented a form of out -patient care, and this hospitals to which people of means offer assistance system prevailed until it was superseded, under an is of less account: philanthropic gifts are made to edict of Constantine in 335 A.D., by the gradual the tiny rural hospital as well as to the great teaching development of Christian hospitals.The healing of institution.Indeed, it sometimes causes a little em- the sick in the open air was a feature of Christianity barassment to the authorities when a village unit is from its birth; and among the hospitals set up in the provided with an elaborate operating room far beyond 4th century A.D. was the celebrated foundation of its needs, or an x -ray set that no one in the area knows St Basil at Caesarea in Cappadocia, about 500 miles how to use.In a very large number of countries, east of Antioch.This hospital, which stood as a however, the voluntary hospital is still the centre of model for many others, consisted of a large number medical care, in cities, towns and villages.Until of buildings, including houses for doctors and nurses, fairly recently not a few of these hospitals have been rehabilitation workshops, and industrial schools. maintained almost wholly by voluntary funds, subject Among the earliest of the residential institutions only to small payments by patients or in return for were hostels for lepers, but simple nursing homes for special services rendered to public bodies.Since the sick travellers and the afflicted poor had been known end of the war, in most countries, the constantly in Asia for many centuries before Christ.In Europe rising costs of medical care have rendered purely also there are a number of mediaeval foundations. voluntary support no longer possible, and considerable Among the oldest are St Bartholomew's Hospital subsidies are now being given from public funds, - (1123) and St Thomas's Hospital (1200) in London. central or local. During the 14th and 15th centuries hospitals spread The steadily rising costs of hospital care have served all over Europe, and a limited amount of specializa- as a stimulus for new financial expedients.By far tion of function took place; but it was not until the the most important of these is the system of pre- first half of the 18th century that hospitals with the payment, under which a small sum paid at regular present -day outlook of cure rather than custody began intervals ensures for the worker and his family coverage to emerge.It took more than a century after that, for a defined part, or the whole, of the cost of treat- when the great discoveries of bacteriology were applied, ment in hospital.Pre -payment schemes appear in before hospitals could be regarded as reasonably safe many forms.The best of them are the simplest and for the patient.From this time onwards a large most inclusive, covering the entire family and all its construction programme was carried out, mostly by hospital needs.Short of this, a number of schemes voluntary agencies.The chief exception to this rule are limited in one way or another -for example, to a was the mental hospital (or asylum) for which the restricted number of days' treatment, or to the ex- State generally undertook financial responsibility.In clusion of certain diseases, or even to a predetermined many countries provision for the poor was made on a maximum in a given year.In a few countries the similar basis, the principle being that governments appearance of commercial pre -payment plans, offering should be expected to take over only what might a wide range of benefits and at times varied conditions be described as " residual responsibility ", making of acceptance, has complicated the issue of health public provision for those whose care lay outside the insurance in general and hospital payment in particular. 68 FIRST REPORT ON THE WORLD HEALTH SITUATION
In an increasing number of countries, especially those drew a sharp distinction between general beds for in which there is little background of voluntary pro- acute illness and those provided for long -term illness, vision, the hospitals have now become a government such as mental disorder, tuberculosis, and general service.The system may be part of a general insurance chronic sickness.It was suggested that, under the scheme or a separate responsibility directly financed conditions obtaining in the United States, a figure to be and controlled by the State.In some cases all treat- aimed at was between 4.4 and 4.7 beds per 1000 for ment is free of charge at the time of need, but in others a acute disease, and an additional 2.3 -2.6 per 1000 relatively small number of pay -beds has been retained. for chronic disease and convalescence.The Bhore Where a hospital system has long been established, Commission in India, which found an existing supply local bodies may be the real owners, but they receive of 0.24 beds per 1000 in 1946, recommended an a government subsidy to cover their inevitable deficit. expansion to 5.65 beds, including provision for special The number of hospital beds which a country re- diseases.The corresponding figures for the United quires depends upon many factors, apart from the Kingdom were 4 per 1000 in rural areas, rising to 6 basic items of disease prevalence and the age- compo- in urban, and an additional 2 -2.5 to cover chronic and sition of the population.In the more remote areas special diseases.Since that time certain important the educational level of a people and their attitude changes have taken place, both in practice and in out- towards sickness are important.The hospital may be look.In the first instance, the recent victories against regarded with suspicion, or for various reasons home the common infectious diseases of childhood, the care may be preferred; and even in the economically promise of success in fighting malaria, tuberculosis advanced areas the existence today of a comprehensive and a number of other causes of serious disability medical care organization, and a tendency to treat have tended to lower our estimate of the number of all but the most serious illnesses outside the hospital beds to be provided in these categories.Secondly, may considerably reduce the public demand for insti- the growing co- operation at the local level between tutional care.Effective community services in pre- the general practitioner and the hospital, and the ventive medicine and the promotion of health will combination of preventive measures and health pro- have the same effect in the long run.Not only that, motion with treatment, have placed new emphasis on but the modern provision, in clinics and out -patient the value and extended possibility of home care under- departments, of experienced staff and the equipment for taken by a health team.In other words, the increasing prompt diagnosis and early treatment of disease will stress being laid upon community development may have a further effect in lowering the demand for in- well have a decisive influence on our estimates of patient care and in shortening the period of treatment. the need for domiciliary care as opposed to hospital In the environmental sphere the housing of the treatment. people, and particularly the size and accommodation It would be premature to emphasize too strongly the of the individual dwellings, may be the determining possibility of any substantial reduction in hospital factor in the choice, on social grounds, between requirements for many years to come.The serious hospital and home care.From the point of view of gap between needs and their fulfilment is only too the nation as a whole, however, the economic level obvious in many lands.And, further, as has been of the people is critical.There are many countries mentioned already, as a country develops economically in Asia and Africa, for example, in which the number and industrially, its first cry is for treatment rather of beds of all types amounts to fewer than one per than for prevention and health promotion.In African 1000 population.In 1954 Iran had about 0.5 beds territories, for example, the urge to proceed with the per 1000 population, and Nigeria as few as 0.35.On construction of elaborate and costly hospitals has the other hand, France had at the same time about been very great, if only on the grounds that a hospital 15 beds per 1000 population, and the United Kingdom carries prestige and is evidence of material advance had 10.It is a notable fact that some of the smaller in the social field.It is at least doubtful whether the countries which have only recently accepted hospital number of hospital beds is a good index of social provision as a State responsibility have already made progress.The steady development of rural health remarkable progress in hospital construction. units and of corresponding establishments in the How many beds are required ? A federal study in more populous areas should in time go far to meet the the United States of America, published in 1953,1 needs of all but those who require urgent treatment or complex diagnosis.The most pressing requirement, 1 REED, L. S. & HOLLINGSWORTH, H. (1953) How many however, is not an increase in the number of beds, general hospital beds are needed ?A reappraisal of bed needs in relation to population (US Public Health Service Publication but the integration of the service at national, regional 309), Washington, D.C. and local levels. INSTITUTIONS AND FIELD ESTABLISHMENTS 69
Hospital organization and undertake private practice in addition to their salaried hospital appointments.The general practi- The general tendency in hospital organization is in tioner was at first virtually excluded from hospital the direction of increasing control and supervision work, but the present trend is towards offering him by local, provincial, or national governments.There clinical appointments, at least in the smaller units. are notable exceptions, such as the Netherlands, where There is a growing co- operation between the hospital the voluntary tradition in health services is exception- service and the family doctor.The central control of ally vigorous, and the United States of America, where hospitals is delegated to a large extent to Regional the pattern of voluntary hospitals built by local civic Hospital Boards, and the day -to -day executive respon- groups or religious organizations is highly developed, sibilities are carried by smaller units called Manage- and the tradition of private medical care is strong. ment Committees.All the members of Hospital In both cases the rising costs of hospital care have led Boards and Management Committees serve on a to special planning with the object of preserving the voluntary basis and receive no remuneration whatever. voluntary principle.The most important of the In addition, there is a steadily increasing army of measures adopted is, of course, insurance in one form voluntary workers who give their time and energies or another.The " Blue Cross " scheme in the United to the National Health Service -for example,in States might well have been adopted in the United maintaining libraries, providing occupations and other Kingdom and in a number of other countries had interests for patients, and supplying transport for it not been for the disruption caused by the war. patients and their relatives. Even in the United States, however, the federal and In other parts of the British Commonwealth a state governments have found it necessary to con- similar design can be seen.In New Zealand, for tribute financially to the construction of new hospitals instance, the hospitals are under the direct control of since 1946. A great deal is accomplished by voluntary the Department of Health.As a result of coiísolida- action, notably the work of the American Hospital tion of the law, the new system will achieve greater Association, in promoting improvement in the stan- integration at the level of the Hospital Boards, and dards of hospital service.Hospitals in Canada also at the same time provide for financing the entire are largely independent institutions run on a voluntary service from central sources.In Australia the various basis, but they are gradually coming under the indirect states follow their own pattern of executive control, influence of government through systems of inspection but there is a tendency to increase the amounts of and licensing.In some cases the provincial authority central subsidy and indirect control of this kind. contributes up to 90 per cent. of the hospital costs, In the Union of South Africa all types of hospital and it is inevitable that it should exercise a considerable are predominantly governmental, and hospital care degree of supervision. isvirtually complete as a publicservice.Ina In the Scandinavian countries the pattern differs to number of the provinces, however, the provincial the extent that practically the whole of the hospital authority contributes up to about half the cost of the system is under government control, primarily under service. the various units of local government.Except in the Countries which have more recently reorganized smallest units, the Swedish hospitals have a full -time their services tend on the whole towards centralization. salaried medical staff.About 90 per cent. of the In Egypt, for example, nearly all the hospitals are now expenses are paid by tax funds, and 10 per cent. are under the Ministry of Health, although the two great paid by the patient, or, more usually, by his voluntary teaching hospitals have a good deal of autonomy. insurance.In the Scandinavian countries thereis Direct control of minor administrative matters is apt little central control over the daily operation of institu- to lead to delay, and it is important to strike the right tions, especially the large general and teaching hospi- balance between independence and integration. A tals, but planning and design, as well as general similar plan of central control is to be found in other policy,are under the supervision of thecentral Arab countries such as Syria and Lebanon.Nations authority. which have recently become autonomous have shown Among the nations of the British Commonwealth a strong trend towards the governmental control of there are plenty of variations, but mostly within a hospitals.This istrue of Ceylon, and the same common pattern.In England, for example, hospital general arrangements operate in Burma and Pakistan careisfinanced almost wholly from the general and in the three neighbouring countries of Viet Nam, revenues of thecentral government.The junior Laos and Cambodia.In a very large nation like medical staff is on a full -time salaried basis, but senior India considerable delegation of hospital control to specialists and consultants are part -time to some extent the states is necessary and desirable, but funds for 70 FIRST REPORT ON THE WORLD HEALTH SITUATION construction and development are being found from for the first time in the wards of his unit, after the central sources to a considerable extent. resident medical officers have made a provisional The non -self -governing territories are, as a rule, diagnosis.It was the great heart specialist, Sir James centrally controlled and financed in relation to the Mackenzie, who first put forward the idea that the hospital services.Often there are a few private insti- senior consultant should be in the out -patient depart- tutions in city areas, but the mass of the people receive ment rather than in the wards of a hospital.This medical care from government dispensaries, clinics, concept of functions was stated at the beginning of the and hospitals.Private medical practice is relatively present century but is only now claiming acceptance. uncommon.In the smaller units, as in many of the In accordance with this approach the out -patient Pacific islands, the situation gives strength and purpose department has become the most important element to the combination of preventive and curative work of the system, and eventually the major emphasis at the local level, including, where necessary, the pro- will be placed on ambulatory patients rather than on vision of a small number of beds in rural health units. the bedridden.The hospital is no longer a fortress The rich development of social security schemes in for the bedfast sick, but rather a community centre some of the countries of Latin America has provided in which the higher medical skillis concentrated. opportunities for new hospital construction.For the The enlargement and improvement of the hospital rural populations in these countries public hospital out -patient department is the most obvious way in care is the rule, and these units are under the direction which a hospital can extend its influence beyond its of the central authority.Under these authorities walls to the homes of the people.By such means it there has been a considerable expansion of institu- can be brought into an intimate relationship with tional provision, and a welcome movement towards general practice and also with the preventive work integration. carried out by the health officer and his nursing and In conclusion it may be said that, while local and sanitary staff. regional patterns of hospital care differ considerably A study of the replies received from many countries in detail, the governmental tendency in most countries reveals that the use of hospital out -patient departments is unmistakably in the direction of increasing central to provide home care services is still in the stage of participation.No doubt the primary reason for this cautious experiment.In the promotion of this idea is the high and rising cost of hospital care, but in one can learn a good deal from the practice in a large principle the most important factor is the recognized number of the smaller territories, as well as from that need for greater integration to achieve a rational in the remoter areas of the more industrialized countries. distribution of the available services. A further prin- In northern latitudes, for example, it is usual to com- ciple, and one which underlies much of the thinking bine in a single " rural health unit " the home care in this sphere today, is the desirability of securing services of the general practitioner, a few beds for closer integration of the health services -the treatment patients in need of short -term care, and the public and restoration of the patient, and, in the same health work of nurse and midwife.The various context, the prevention of sickness and the promotion clinics are held at different times on the same simple of health. premises, and the whole range of health and medical care is combined.Plans of this nature, suitable for Out -patient departments the differing circumstances, are in operation in the scattered village groups of Indonesia, the islands off For many years the out -patient department of a the coasts of Scandinavia and Scotland, and the great hospital has been its main link with the outer world. archipelagos of Oceania.The situation in populous It has been the admission channel for accidents and areas is always held to be fundamentally different. emergencies, and in most cases the checking point for It is frequently assumed that the pattern of the city routine admissions to the wards.The out -patient or large town should be designed to provide one or department has also been one of the chief teaching more great general hospitals, and in most cases, a centres for medical students, and in the larger units group of specialized institutions such as mental hospi- it has often been provided with small demonstration tals, orthopaedic institutions, and hospitals for com- rooms in which groups of undergraduates have re- municable diseases.In some of the more recently ceived theirfirstclinical practice under qualified developed plans these units are being grouped together supervision.On the whole, however, the out -patient to create " hospital cities "; but more commonly the department has been regarded as an ante -room to true general hospital is situated in or near the most populous medical care, and it has been the custom from time area of the city, while the specialized units have the immemorial for the clinical chief to see his patients benefit of less congested surroundings.In a number INSTITUTIONS AND FIELD ESTABLISHMENTS 71 of countries there has been a movement lately to also for routine medical supervision -for example, transfer the general hospital also to the more healthy during a period of sickness prevalence. outskirts of the city, leaving in its place a highly organized polyclinic or out -patient department.It Health centres, rural health units, etc. has been found that only a small proportion of hospital beds -mainly for the care of casualties and urgent There is some confusion in the various reports from cases -needs to be situated in city surroundings.The governments as to the precise meanings of such terms great majority appreciate, and benefit by, a hospital as " health centres ", " polyclinics ", and " health sta- unit of simple design, in " country " surroundings, tions ".The expression " health centre " is, perhaps, although not far from the city.This provision how- subject to the greatest variety of interpretations.It ever, does not solve the main problem of providing was applied in 1920 in the United Kingdom to an out -patient services for urban dwellers at a reasonable institution which provided under one roof both distance from their homes.The most acceptable general medical care of patients by a group of medical solution, it seems, is for the authority to build health practitioners and preventive services under the public units within the new estates and on the urban fringe health authority, such as maternal and child care, generally, on the same general principles as in the school clinics, and communicable disease control. rural health units referred to above.In the huge In certain countries the provision of " health centres " urban conglomerations of today people cannot be (or polyclinics) is a matter of State policy, and these expected to leave their homes for lengthy periods in institutions are generally maintained by the govern- order to visit a central out -patient department for ment through its local departments.In the United diagnosis or care as ambulant patients.On the other Kingdom, the creation of health centres was made a hand, it is not difficult or unduly expensive for the statutory undertaking under the National Health hospital authorities to go out to meet the patients, Service Act of 1946, but in point of fact very few of by setting up simple " urban health units " primarily these centres have been erected, mainly for financial under the charge of a group of local general practi- reasons.One of the principal difficulties in practice tioners, but linked closely with the main hospital on was that the provision of public health services in a the one hand and the public health department on the health centre involved a much greater expenditure in other.The aim of the service would be to make and money and space than the establishment of half -a- maintain contact with the family and home life of the dozen or so consulting rooms for general practitioners. people.In a number of countries which have intro- The result of this was that the general practice orga- duced hospital insurance plans it has been found that nization represented only a very small part of the there is increasing pressure on bed accommodation as whole centre and employed only a few of the practi- a result.The conclusion reached is that only the tioners in a given area.Yet to have admitted more extension of insurance to cover the general practi- than six to ten practitioners to one centre would have tioner's services in the home and dispensary will caused too great a congestion of patients.Perhaps reverse this process and reduce the excessive cost of the principal hindrance to success was that so many hospital care.In recent years several hospitals have doctors of the area were left out of the scheme, deliberately introduced " home care programmes " on either by their own choice or because of lack of room. their own account, to reduce the pressure on hospital It should be observed that the term " health centre " beds. One of the features in some of these programmes is used in reports to denote a whole range of services is the skilful use of transport, by means of mobile from the most elementary rural health unit to the most clinics, special ambulance transport, and, in widely complex polyclinic; perhaps the simplest way of ap- scattered districts, the " flying doctor service ".It is proaching this question is to go back to the basic unit worth bearing in mind that the mobile clinic, except and build up definitions from that. A rural health in certain river and island services, is rarely a good unit has been defined as " an organization providing substitute for a permanent rural unit.The latter or making accessible, under the direct supervision of gives to its area a feeling of security that mobile ser- at least one physician, the basic health services of a vices cannot supply.One of the principal uses of the community ".With this definition in mind we should mobile clinic, to which reference will be made later, is refer to any smaller unit, served by a nurse or other its application to medical care in a group of factories. health officer,as a " rural health station ".This The clinic truck is able to move quickly from one would apply, so long as a physician paid an appro- workplace to another, and this saves a great deal of priate number of regular visits and supervised the waiting and loss of working time.It can be used for station.In the same manner one would define an daily dressing and other forms of minor surgery, and " urban health unit " and its corresponding station. 72 FIRST REPORT ON THE WORLD HEALTH SITUATION
It is evident that units of this kind should be closely and Indonesia, and indeed in all areas in which com- associated with a larger administrative and technical munications are poor and wide stretches of country organization, so that specialized assistance could be separate one village or settlement from another. obtained without question and with as little delay as The situation in the bigger cities has been causing possible. anxiety.In many of these a rush of immigration has It has been suggested that the rural health unit given rise to difficulties in providing medical care for should supply the following services, which are re- families living on the crowded fringe areas.It has garded as basic: been found possible in some areas of this kind to set (1) Maternal and child health; up local health units, as in Singapore and Hong Kong; (2) Communicable diseases control; in other cities use has been made of group practice to meet the deficiency, but it is financially difficult for a (3) Environmental sanitation; group of general practitioners to make special arrange- (4) Health education of the public; ments to deal with such a situation.The trouble lies (5) Public health nursing; deep enough to demand special investigation and, in (6) Medical care (varying to some extent with the appropriate cases, the provision of some form of needs of the area and the accessibility of the larger subsidy. hospital centres). The meaning of the word " dispensary " also is subject to varying interpretations.In many of the The word " clinic " ought by its derivation to mean old- established towns the public dispensary is simply an institution providing beds for the sick, and indeed the ancestor of the modern out -patient department. it would be best to limit its use to this essential feature. This term has been widely used, in addition, to denote In practice, however, " clinic " is often used to describe a doctor's " surgery ", especially when the latter was the office of a clinician in the physical sense, or even detached from the physician's home.In time past the the consultative session which he holds in that office. designation was apt enough, because it referred to a It was no doubt for this reason that a group of clinics, place in which the doctor dispensed his own drugs - rendering to patients a wide range of services in the and dispensaries of this kind are still extant.At the same building, was described as a polyclinic, and the present time it is common for that part of an out- derivation once more makes the meaning quite clear. patient department which is concerned with issuing The term " health centre " should in these circumstances medicines to be called " the dispensary ".It would be be confined to buildings in which preventive and cura- desirable to retain this name for use in its proper tive services are combined.The essential feature of a derivatory sense -namely, as a place where treatment polyclinic is the combination of highly specialized in the form of medicine is given.The term " out- diagnostic and curative services -with perhaps bed patient department " is much more satisfactory as a accommodation for cases under observation -in a designation of this vital hospital service -the essential single building.The word " health " in this context link between hospital and home.The term " dispen- implies the integration of preventive and curative sary ", however, is widely used in Africa to denote services in one building or group of buildings, and it simple establishments employing auxiliary staff for the should not be used to denote an institution where only treatment of minor ailments and for the supply of therapeutic services are provided. first -aid dressings. In a large number of countries the provision of rural health units, by whatever name they are called, is widespread.So far as hospital accommodation is concerned, the remoter units would be expected to 3.STATISTICAL SERVICES make arrangements to include a few beds for mater- nity cases and for medical and surgical emergencies In recent years there has been a growing recognition only. A high proportion of these units, especially in on the part of health administrations of the value Asian countries, have made provision for maternal of vital and health statistics as a means of finding and child welfare, but in fact few of them appear to out the population groups and diseases requiring have sufficient nurses or even auxiliaries.It had been particular health action, as well as for the subsequent suggested that, in order to secure the greatest efficiency, evaluation of such action. there should be, in addition to the physician, some five Much progress has been made since the end of the to ten nurses, several sanitarians, and a substantial 19th century in improving the quality and the inter- number of auxiliary workers.Units of this type are national comparability of mortality statistics by pro- especially suitable for such countries as India, Nigeria, viding uniform definitions of vital events, nomencla- INSTITUTIONS AND FIELD ESTABLISHMENTS 73 tures of diseases, rules of certification, classification, Returns of hospitals may be exploited more system- and tabulations of causes of death. atically where they constitute the only source of infor- WHO has taken an active part in this work since mation on the local pathology.Where physicians are 1947, its endeavours culminating in the issue, in 1957, not available, it seems that much information might of the English, French, and Spanish editions of the be obtained from returns of medical outposts manned revised International Classification of Diseases and by medical auxiliaries, if the lists of pathological condi- WHO Nomenclature Regulations.The fact remains, tions placed at their disposal were adapted to their true however, that the standard methods of compiling diagnostic ability under conditions of practice and proper mortality statistics require both an abundance therefore included clinical symptoms as well as precise of physicians and a well -developed administrative pathological entities.Similarly, much might be in- machinery for the registration and compilation of data ferred from death records, made by lay officials or -two conditions which are present in only a minority village chiefs, containing rough indications of age and of countries. a crude statement of illness, symptoms, or accident It is estimated that only 80 per cent. of the world's preceding death. population was enumerated in the last decade, and A review of morbidity statistics in the various coun- only 33 per cent. of the total number of deaths was tries shows the paucity and lack of comparability registered in 1951 -55.1 The proportion of deaths of of the data available.Reports of notifiable diseases which the cause is known is far smaller still, and the constitute the most common source, but their com- WHO Annual Epidemiological and Vital Statistics, 1955, pleteness varies enormously from one country to the issued in 1957, do not include more than forty coun- other, according to the number of physicians available tries for which these data are both available on a nation- and the local practices. wide scale and deemed reliable for international com- Hospital statistics are often compiled in territories parison. where medical care is confined to government institu- Both United Nations experts in vital statistics and tions.They are seldom available, on the other hand, WHO experts in health statistics have recommended in countries where care is given chiefly by medical that countries unable to produce statistics covering practitioners; their interpretation would be delicate in the whole of their territory initiate pioneer registration these countries, as they would represent a heavily areas in their cities or selected areas administrative arrangements can be made. Where they exist, sickness records of social insurance There are, in fact, many towns throughout the world organizations do not cover a fair sample of the popu- where vital registration is practised and where crude lation and as a rule leave much to be desired as vital rates could be computed, distinguishing between regardsaccuracy of diagnoses.Sicknesssurveys residents and non -residents.There are also many have been too few and too restricted in both time and cities in which physicians would be sufficiently numer- extent to provide a wide basis for estimating global ous to certify the cause of most deaths, and where morbidity and its causes.Although much has been arrangements could be made to ascertain the cause of done by national committees on vital and health death in those patients not attended by doctors.It is statistics to define concepts and terms used in this hoped that statistics based on such material will be and other forms of morbidity statistics, standardization compiled in increasing quantity, and the mistake of nomenclature has not yet been achieved, and, in thus avoided of publishing as national totals data spite of their great intrinsic worth, sickness surveys of varying degrees of completeness and reliability have not yet reached the stage where they can be used obtained from separate cities and other local govern- internationally. ment units. This brief review of the state of health statistics Meanwhile, acting on the recommendation of its would not be complete without a reference to the Expert Committee on Health Statistics, WHO, through critical study made at the request of the United regional seminars and field experimentation, is seeking Nations by the WHO Expert Committee on Health methods which may provide health administrations Statistics,' and by a special studygroup,2of the various with information on the health situation of territories rates and indicators used for the measurement of in which physicians and trained officials are too few " health " as one of the components of social develop- to produce vital and health statistics according to ment.Their relative merits and shortcomings have standard methods. been compared, and their relative sensitiveness has
1UNITED NATIONS, STATISTICAL OFFICE (1956) Demographic 1 Wld Hlth Org. techn. Rep. Ser., 1957, 133 Yearbook, 1956, New York, p. 14 2 Wld Hlth Org. techn. Rep. Ser., 1957, 137 74 FIRST REPORT ON THE WORLD HEALTH SITUATION been measured by the objective test of the discriminant work together and combine with their general service function.The application of this test showed the the preventive work which is associated with the public proportional mortality above the age of fifty to be the health department.Preventive and curative care are index of choice (see Chapter 2, page 14). carried on side by side in the same building. Another method of approach, which isgaining ground in some countries, is for the local hospital 4.DOMICILIARY HEALTH SERVICES through itsout -patient department to organize a system of home care in relation to its own services; The reports submitted by many countries indicate this includes follow -up care of the chronic sick in that there is an extensive movement in the direction their own homes, supervision of the aged and arrange- of bringing medical care to the homes of the people. ments for them to be admitted to hospital when The method of reaching the home has been undergoing occasion requires.The family doctor retainshis a process of evolution during the past few years.Until personal responsibility for the welfare of his own comparatively recently general practitioners were ac- patients and for continuity of care in the family customed to work in isolation and in competition.In setting.The special feature of the system is that the a large number of countries today competition is being out -patient department becomes recognized as the steadily replaced by collaboration, and isolation is proper channel through which the family doctors of giving way to the formation of the group and the team. the area can obtain help for their patients, either in These two words do not mean the same thing: the social care or in laboratory diagnosis.In a few areas " group " is best represented by a number of doctors the out -patient department also brings the local general who voluntarily work together in the same general practitioners into contact with the health officer and practice, whereas the " team " comprises a number of with the services which hisdepartmentisready health workers who, under the guidance of the physi- to render. cian, operate a local health unit.Units of this kind A general practitioner has been defined as " a doctor are now well developed in some countries, notably in in direct touch with patients, who accepts continuing Asia and Latin America.They are also well suited responsibility for providing or arranging their general to the conditions of many island territories, and to the medical care, which includes the prevention and treat- rocky fringes of north -western Europe.Group prac- ment of any illness or injury affecting the mind or tice, on the other hand, is being organized more any part of the body ".1 One advantage of this defini- extensively in industrialized countries, both by private tion is that it brings out an essential feature of general practitioners (as in the United States of America) and practice -namely that the doctor provides continuity by doctors in public services -in cities, towns, and of care.In some respects this continuity is more even in groups of villages.The advantages claimed important than the practitioner's coverage of the for the group system are: that it enables prospective entire family.In certain countries, such as the United patients to feel sure that they can obtain medical atten- States of America and Poland, the extensive practice dance at any time of day or night and during public of paediatrics as a specialty has already created a holidays; that several practitioners working together division in total family care; and, in any case, the are given the opportunity for consultation among principle of free choice of doctor would allow younger themselves and for getting the immediate help of a members of the family to choose their attendant, colleague in a difficult case; and that the group can applying their own, rather than their parents', criteria. maintain better premises, with more nursing and The " family doctor " tradition is strong in France, auxiliary assistance, than any one practitioner can the Netherlands, and some other European countries. provide on his own behalf.In addition to this, a Irrespective of the importance attached tothe group of practitioners can often achieve some degree maintenance of health and the prevention of disease, of minor specialization -for example, in midwifery therealstarting -point for any discussion of the or paediatrics -and obtain a larger range of modern physician's task is the care of the sick.Most medical equipment than a solitary general practitioner.From practitioners are called in by a family when one the point of view of the doctors concerned there is the member of the family is sick, and the doctor's first additional advantage that they can have regular periods obligation is to establish a diagnosis and to institute of recreation and adequate holidays. the remedies which he believes to be appropriate. Practitioners attending health centres may be on a Good clinical practice, although based on scientific whole -time basis, but more commonly they enter into part -time contracts. The essence of the health centre i HUNT, J. H. (1957) The renaissance of general practice. principle is that a number of general practitioners Brit. med. J., 1,1075 INSTITUTIONS AND FIELD ESTABLISHMENTS 75
medicine, has always included much besides. Clinical and in parts of Asia -and, in fact, in all the less exmination in the narrow sense tells less than half the populated areas of the world -are setting up, under story of sickness.Diagnosis is rarely complete and various names, what might be conveniently called treatment is generally wanting in a vital respect unless " rural health units " (see page 71).The essential the doctor's conception of medicine relates the patient feature of this plan is that it provides an accessible to his environment.That environment contains his nucleus for a real integration of health and medical home and family, his work and play, and the social care.The physician is in charge of the health unit, conditions in which he lives and moves.It is clear, and must be responsible for its organization.Never- then, that the doctor's diagnosis is both clinical and theless, he is the head of a team which may consist of social, and one of the qualities of a good doctor is his several nurses, one or more sanitarians and some ability to assess the social situation. auxiliary staff.The doctor may be in charge of a In everyday practice the doctor is not alone in his group of rural health units of this kind, and it would medical work. Among the most striking advances in be his duty to arrange with the nurse for regular domiciliary health services today is the movement visiting periods, and with the sanitarian for special towards providing the general practitioner with what visits.In addition to this he will always be on call might be described as " help in the home ".One of for any real emergency. A common arrangement is the first assistants of the doctor in time past was the for one nurse to be resident in or near each rural health district nurse.It is she who has carried out all the unit, with appropriate arrangements for holidays, time functions that the doctor is able to delegate.She off, etc., with her neighbouring nurses attached to the undertakes the care of midwifery patients, either as same group.The doctor, for his part, is in charge of a a midwife or as a maternity nurse or, more commonly, group of units and has the same kind of liaison with in both capacities; she attends to the needs of the aged, his fellow physicians who are responsible for other and often pays regular nursing visits, perhaps to dress groups.In this way a network of health units is a chronic wound or to provide some service, such as formed with a true integration of responsibility.It massage, which could not be otherwise obtained.The should be understood that this is not a substitute for district nurse also helps the doctor indirectly by calling home care but rather a means of making home care him in when she feels that a patient requires medical more efficient and reliable as a service.People able attention.Doctors in practice have relied a great to reach the unit would normally be expected to deal on the work of the district nurses. attend as they would at any dispensary, health centre, In the more rural areas, and particularly where or polyclinic; but the rural health unit is a flexible communications are difficult, the district nurse usually organization, linking general practitioners with an combines her nursing duties with health visiting.She accessible hospital on the one hand and with the area then becomes a general health worker often to an even health services on the other.Reference has been made greater extent than the doctor.The reason for this to the district nurse.It is always desirable that in rural is that she visits mothers, infants and young children areas she should be specially trained as the public at regular intervals, whether they are sick or healthy; health nurse and combine the duties. whereas, by the very nature of things, the doctor In urban areas the position is different.Commu- himself is able to visit only when called in on account nications are better, and there is, in all probability, of illness.This does not mean that the doctor does no a hospital with its out -patient department near at hand. health work: on the contrary, the good country doctor In considering domiciliary health services, the question uses the opportunities given by his visits to " see the at once arises :" Is this an adequate provision ? ". family ", answering many questions about health and In the effort to extend their services to the community, giving a great deal of practical advice on these a number of hospitals have gone beyond the expansion occasions. of their out -patient departments and have organized The combination of doctor and district nurse has home care programmes by which the staff and facilities created certain difficulties.These are mainly due to of the hospital are brought directly to the patient in the fact that there might be two or more doctors in his home.This idea has been implemented, for competition in a given area, all perhaps seeking the example, in the well -known scheme of the Montefiore services of the same nurse.And again, the district Hospital, New York.This institution,itistrue, nurse is able to call at the homes of the people only at initially served a special function :it was devoted limited intervals, at most perhaps once a day, but in mainly to the care of chronic diseases.In the course scattered villages the intervals might be considerably of this pioneer work, it was found that many patients longer.In order to meet thisdifficulty,quite a who either were suffering from long -term illness or had number of countries, especially in South America passed the summit of an acute illness could be cared 76 FIRST REPORT ON THE WORLD HEALTH SITUATION for with more understanding and less expense in as the home conditions are carefully watched so that their own homes.This was always subject to the the mother does not return immediately to the full proviso that the home met certain minimum physical round of domestic life. and social standards in such matters as cleanliness and In the United Kingdom the shortage of hospital the absence of overcrowding.The system implied that beds has also been met to some extent by the develop- physicians, nurses and medical social workers from ment under the National Health Service Act of a the hospital staff would pay regular visits to their domestic help service.This enables many patients to patientsat home.This system was applied to get home earlier than they would otherwise have done, municipal hospitals in New York City, and in 1952 and it provides safeguards against overwork.The it was calculated that there was a saving in hospital system also enables many patients to remain at home beds of about 16 per cent.It was also observed that when they would otherwise have had to go to hospital. these home care programmes not merely saved beds; A similarservice has recently been launched in they rendered a better quality of medical care in Denmark on a national scale, and the practice has circumstances more agreeable to the patient and his spread to a number of other northern countries.The family. " home -maker " service in North American cities is What was begun as an experiment in the care of the being provided mainly by voluntary social agencies. chronically ill has also been applied to patients con- One of the advantages of these methods of extending valescing from acute illness or a surgical operation. the services rendered by the out -patient departments The essence of success is collaboration between the of hospitals is that the ultimate need to integrate hospital, the general practitioner and the medical social curative with preventive medicine is served thereby. workers.The special function of the last -named is to The resources for early diagnosis, treatment and after visit the home in advance and report on its suitability, care are strengthened within the community itself. and later to make periodic visits in order to ensure There are always dangers in extensions of this kind. that there is a proper adjustment of medical care.It is Excessive pressure for economy in any branch of perhaps an over -elaboration for the hospital to organize health administration might lead, if it were not care- a system of home care of this kind; such a procedure is fully watched, to an over -development of home care suitable in special cases where the general practitioners service at the expense of the sick.One of the func- of the a tions of the out -patient department should be to for this purpose, but any intervention of the hospital ensure that itsoutward services of this kind are in the homes of the people would not be a happy designed for the better care and comfort of the sick arrangement without the full collaboration of the and not merely in the interests of administrative saving. general practitioner. A good modern example of the A further duty of the out -patient department, in its home care system has been developed in parts of liaison with general practitioners, is to improve the France and Belgium, where the assistantes sociales are quality of medical care in its area.Hospital and well qualified to follow up patients, since they are specialist services in most countries have developed trained both in nursing and in medical social work. separately from general practice, and the family On the whole it seems that a home care programme of doctor has been late in sharing with them the advances this kind might be especially appropriate to populous of medical science.Where the hospital is run on a districts on the urban fringe of a city.Transport is " closed staff " system the risk of leaving the general always a difficulty and accessibility to a hospital is an practitioner out in the cold issubstantial.Many essential feature of this scheme.In the more widely hospital authorities are, in fact, aware of this and, scattered rural areas the network of health units often under governmental arrangements,conduct appears to be the system of choice. systematic post -graduate training for general prac- The provision of nursing and medical care is not titioners who are not on any hospital staff. the only method by which the shortage of hospital beds can be relieved.In recent years the idea of getting patients up within a few days of a surgical operation 5.INSTITUTIONS FOR THE PRODUCTION is gaining strength, as it has been found that there are AND CONTROL OF DRUGS, less risks of circulatory disturbances when a patient is BIOLOGICAL PREPARATIONS, AND FOODSTUFFS moved as soon as possible.It is a good thing to get a patient on his feet.The same idea has been applied Drugs to maternity, and it is now common for a woman to be In the reports from governments the references to up and about within two or three days of her confine- the control of drugs deal with administrative organiza- ment.This is probably satisfactory enough as long tion and ways and means of collecting information INSTITUTIONS AND FIELD ESTABLISHMENTS 77
and of keeping it up to date.The authorities con- in Geñeva in December 1956,1 and in particular with cerned do not enter into technical details of assay and the suggestion that information sheets on new pharma- laboratory research.This limitation was implicit in ceutical preparations should be obtained by WHO, the questionnaire sent to them. A number of returns collated and distributed to national health authorities, expressed some anxiety on the part of governments pharmacopoeia commissions, etc., at an early stage about changes in commercial production and distri- of the introduction of the preparation.In the opinion bution which added to the difficulties of national of the Expert Committee this would afford the best control.These changes may be briefly described as possible means for dealing with the great influx of follows.There was a time, not so long ago, when new preparations on the market.The Committee pharmaceutical preparations were produced ina agreed that the active collaboration of the pharma- steady flow, and the interval between production and ceutical industry was indispensable to the success of marketing was sufficienttoallow for laboratory this project and noted with appreciation that the reports examination and report.The pharmacopoeia was from members of the Expert Committee who had con- regarded as a stable compendium -a dictionary of sulted national administrations and some sections of specifications -which held its own until an addendum the pharmaceutical industry suggested that consider- or another leisurely compiled edition was published. able support would be forthcoming. The situation has now changed radically in rate and Information sheets would include the systematic volume of flow.Hundreds of new medicinal sub- chemical name, international or other non -proprietary stances are introduced into the materia medica every names, and trade names known or contemplated in year.The very number alone presents hazards to various countries, names of manufacturers, molecular health, as has recently been demonstrated, if only formula, molecular weight, structural formula, refer- because of the short time that elapses between the ences to literature on syntheses of the final product, production of a new substance and its use in thera- various physical data (melting -, congealing -, freezing - peutics.The new drug, as it were, rushes into print. or boiling- range; refractive index; optical rotation; Less than a generation ago the interval ranged from density; visible, U.V. and I.R. absorption; crystallo- five to ten years.Today it may be as short as six graphic data; viscosity; pH of solutions; solubility), months; side reactions and toxicity cannot possibly be identification reactions, assay, assay of pharmaceutical determined in that time.The general practitioner forms, sterilization methods, purity tests and toler- is the ultimate field investigator, and even when he ances for trace impurities, pharmacology, toxicity, side - is working as a member of a group, he needs time and effects, clinical applications, usual dose, range and the judgement of long experience to enable him to give route of administration, specific antidotes (if known) his verdict.Yet in many cases it would be unreason- andreferencestogeneralliterature.Comments able to expect producers to slow down their sequence: would be invited from those receiving the information many new preparations are widely advertised and used sheets, and revised sheets would be used in the pre- soon after their issue, and there ought to be some parationof monographs where required forthe means of securing immediate supervision.The race InternationalPharmacopoeia.Afteratechnical for production is keen, and few countries have labo- examination by WHO the information would be ratories and trained staff capable of protecting the circulatedto Member Statesas wellasdirectly user without delay. to national pharmacopoeia commissions and official The examination of pharmaceutical preparations is controllaboratories,and tootherorganizations a highly complex skill, involving a wide range of or individuals interested in the use of these speci- knowledge.This increasing number of preparations ficationsfortheexaminationof pharmaceutical and the complexity of their content have made the preparations. production of a pharmacopoeia a difficult task.The It was reported that a centre for authentic chemical time taken is long, and the resulting book becomes out substances was being created in Stockholm.The of date so soon. object of the centre is to keep, control, and distribute a In view of this, the Expert Committee on the Inter- restricted number of pure chemicals which could be national Pharmacopoeia, at a recently held session, used for reference purposes by the control laboratories examined the possibility of providing such specifica- of governments and other authorities.The range of tions within a reasonable time after the appearance the collection would be limited to substances used in of the new preparation.In this connexion the Expert the laboratory, in the control of medicaments, and in Committee expressed its full agreement with the views pure research. set out in the report of a Study Group on the Use of Specifications for Pharmaceutical Preparations, held 1 See: Wld Hlth Org. techn. Rep. Ser., 1957, 138 78 FIRST REPORT ON THE WORLD HEALTH SITUATION
Biological standardization dization, and under whose auspices the number of international standard preparations has now risen to Biological preparations such as sera, toxoids, vac- about 70.These preparations continue to be held cines, antigens, vitamins, hormones, antibiotics, etc., by the two international centres mentioned above, and are playing an increasingly important role in thera- samples are distributed to national laboratories for peutic and prophylactic medicine and also in diagnosis. biologicalstandards throughout theworld.This It has been recognized in all countries that this type system functions well, and it should enable control of preparation is different from other pharmaceutical laboratories in all countries to carry out valid measure- products.The main difference commonly employed ments of the potency of biological preparations pro- to distinguish biological substances is that the potency duced by or imported into their respective countries. of such substances can only be evaluated in assays The difficulties are still numerous.For many impor- involving the use of laboratory animals or living cells tant preparations international standards have not or tissues.The performance of such assays requires sofar been established.For example,theonly the knowledge of specialists, and in practically all vaccine for which an international standard prepara- countries the control of biological substances is there- tion is at present available is pertussis vaccine.The fore separated from the control of pharmaceutical standardization of this vaccine became possible be- preparations in that special institutions have been put cause two necessary conditions had been fulfilled : in charge of it.One of the difficulties in the evalua- (1)a dry stable preparation of this vaccine was tion of the potency and the innocuity of biological available, so that one could be confident that the preparations is the fact that the animal responses standard preparation stored in Copenhagen would observed and measured fluctuate with the variation in retain its original potency unchanged; (2) it was shown the susceptibility of the animals.The use of the in extensive field trials of the vaccine in children animal response as a measuring unit istherefore compared with parallel trials in mice that relative unsatisfactory and it was early recognized (by Paul potencies, obtained in a laboratory by using mice as Ehrlich) that the way out of this difficulty would be the test objects, were indicative of the relative efficacy creation of stable standard preparations which could in preventing whooping -cough in children.It is clear be used in comparative assays with unknown prepara- that comparative assays of two preparations in a tions that were to be evaluated.By comparing the laboratory are only useful if the property thatis responses evoked by the standard preparations with measured in these assays is the same as or closely those evoked by the unknown preparations in the correlated with the property we are interested in- same assay, the potency of the unknown preparation namly, the effect of a preparation when applied to can be expressed as a relative potency in terms of a human beings. standard preparation.By defining a unit as the For many other important vaccines international activity of a certain weight of the standard preparation, standard preparations could not so far be created, the potency of unknown preparations can thus be either because stable preparations were not available expresséd in units. (BCG vaccine, poliomyelitis vaccine), or because we In order to avoid the creation of a variety of have no evidence that the laboratory tests actually different standards and units in different countries reflectefficacy in man (typhoid vaccines, cholera action was taken in the early 1920's by the Health vaccines, etc.). Organisationof theLeagueofNations,which Control laboratories in different countries are faced created a permanent commission on biological stan- with many problems.Assays can be carried out on dardization to deal with these problems.Under the substances for which international standards exist, auspices of this body, international standard prepa- but laboratories must decide what assay methods they rations were established for about 30 different biolo- should employ, how extensive the tests should be gical substances before the outbreak of the Second (for example, number of animals to be used), and what World War.These standard preparations were held should be the acceptance levels.(If the level of per- in custody by two central laboratories -one in Copen- formance of an unknown preparation in the laboratory hagen (the Statens Seruminstitut) for sera, vaccines is under a certain fixed " acceptance " level the pre- and other immunological preparations, and the other paration should be rejected for use in man.The in London (the National Institute or Medical Research) definitionof acceptancelevelsinvolvesstatistical for hormones, vitamins, antibiotics and other pharma- complications.)Another problem facing control labo- cological preparations.After the war, this activity ratories is how to deal with preparations for which no was taken over by WHO, which has convened yearly international standards exist and for which there is no meetings of expert committees on biological standar- international guidance. INSTITUTIONS AND FIELD ESTABLISHMENTS 79
In the face of all these difficulties the development regulations.Methods of assay need to be con- of the control of biological substances has differed tinuously revised in the light of increasing knowledge from country to country.In most countries there and the appearance of new preparations for which no exist definite regulations for some substances and legislation exists.In many of the less developed coun- none for others.The regulations, in so far as they tries the control systems are very rudimentary and exist, may be very detailed, giving precise technical cannot possibly cope satisfactorily either with the instructions concerning the performance of assays, or, production of their own countries or with the influx on the other hand, they may be rather vague.Some of foreign preparations. regulations are legally enforced, others are not.In Though international action in this field has thus led many countries the law merely prescribes that control to the creation of many biological standards, there is of biological substances should be carried out by the need for further international guidance.The object official control laboratory, which has the authority to of this is partly to give control laboratories in many choose its own methods and requirements.In Ger- countriestechnicalinformation onthepractices many, for instance, there are regulations covering a followed in other countries, and on the best ways of large number of biological substances, prescribing dealing with control of various preparations; and methods of control which must be carried out in the partly to create a greater uniformity in this work. Paul Ehrlich Institute in Frankfurt; this Institute The present diversity has many unfortunate conse- decides on the basis of its control results whether a quences for the exchange of biological substances preparation should be released for sale.Actually, between one country and another.This often means this applies only to the State of Hesse, but the other double control because therequirements in one states of the Federal Republic have agreed to follow country differ from those established in another. the Hesse rules.In the United States of America, WHO is now trying to give assistance in this field. the National Institutes of Health of the Federal Govern- ment have issued a very complete set of minimum Food additives requirements fortheproduction and control of biological substances.These minimum requirements Until comparatively recent times the production of do not have the force of the law in the various states, food and its distribution were largely matters of local but arenevertheless strictlyfollowed; and there or national concern.Today a great many foodstuffs is a system of inspection and sampling by which all have to be transported over thousands of kilometres manufacturers abide.In the Union of Soviet Socialist under rapidly changing climatic conditions, and some Republics the Ministry of Health issues complete have to be stored for long periods.It would not be instructions on the manufacturing and control methods possible for many of the fresh fruits and vegetables, that are to be used in the preparation and issue of or processed food products, to be sent all over the biological substances.These instructions are prepared world unless chemicals were used to prevent food by committees of scientists, producers and other spoilage. Even as late as 1954, 13 million pounds experts, and there is no problem in enforcing them, of cheese were reported tohave been loston since the manufacturing establishments are all owned account of mould alone.This clearly indicates that by the State.All the same, there is an elaborate further research on the development of new chemical system of control in that the Central Control Institute additives is necessary.On the other hand, the search in Moscow has established, in all manufacturing plants, for proper food protectives and for substances designed a laboratory unit which undertakes an independent to improve the appearance and taste has brought the examinations of the products.The staff of these number of chemicals at present used in food up to units belongs to the Central Control Institute, which nearly a thousand -and hundreds of these substances itself can choose to carry out additional control of have been so employed without sufficient testing for samples sent in from its own control units.In a small their possible injurious effects.The Delawny Com- country like Denmark the whole problem is more mittee, set up in the United States of America in 1951 easily solved, since one single institute has the mono- to inquire into the problem of chemical additives in poly of producing immunological substances for food, reports that in the Food and Drugs Administra- human medicine.This Institute is State -owned and tion Register of 704 chemicals only 428 were con- performs its own control according to its own judge- sidered harmless. ment.In most countries, however, the workers in the It is amazing how little attention some countries control institutes who are responsible for biological -even highly developed ones -have paid tothis substances are faced with innumerable difficulties question.In those countries which took an early because theiractivityisnot backed by complete interestinthe problem many discrepancies have 80 FIRST REPORT ON THE WORLD HEALTH SITUATION occurred in their investigation results and subsequent Furthermore, it was felt that for the guidance of decisions.Some chemical substances permitted as workers in this field, there is a need for uniform food additivesin one country are prohibited in experimental methods, for the biological testing of another.Different colours appear on the lists of food additives.The Expert Committee meeting held permitted food dyes in different countries, and some on this subject outlined procedures for acute, short - of them which are considered as safe in one country term and long -term toxicity tests and provided informa- are thought to be dangerous in another.Substances tion as to the validity of these data and their applica- at one time regarded as safe are removed from the bility to man and the use of margins of safety in the permittedlistand then registeredasdangerous. estimation of the safe level of intake. Outlines of safety -evaluation procedures vary from The problem of chemical carcinogenesis and muta- country to country.Moreover, the use of chemicals genic action of food additives is to be given further in food processing is sometimes introduced unneces- consideration at a later stage by a group having among sarily, with probably harmful effects.Lately a new its members a greater number of qualified workers in danger is causing concern -some of the substances the field of cancer research. used as chemical additives have been shown to have The need for specifications of identity and purity in mutagenic effects. chemical and physical terms through the collection and So the ever -increasing use of chemical substances in dissemination of data on chemical,physical and food has created a new public health problem, and the toxicological properties of individual food additives Sixth World Health Assembly considered it would be and information on pertinent legislation was also useful to make further investigations; consequently, evident. A bulletin listing all cùrrent enactments on a joint activity was established between, WHO and food additives is therefore issued by the Legislative theFood and AgricultureOrganization (FAO). Service of FAO.This bulletin appears at intervals Expert committee meetings have been held,first, as required. to formulate general principles governing the use of Information on food colours has been collected food additives and, secondly, to establish uniform by WHO and tabulated in the form of data sheets. methods for evaluating their safety.The committee Similar documents relating to antimicrobials, anti- entrusted with the latter task concluded that the use of oxidants and emulsifying agents are in preparation. chemicals to improve texture or storage properties, The establishment of a centre to provide information flavour and appearance is justified when the subs- on laws and administrative provisions governing food tances concerned helptomaintain thenutritive additives in different countries, on results of research quality of a food, enhance its keeping quality, make on and evaluation of the safety for use, on accepted foods more attactive to the consumer and provide an procedures, and on specifications and methods of essential aid in food processing.Their use should not, analysis, is of great importance.The aim of this however, be permitted when they disguise faulty pro- centrewould betoservetechnicallydeveloped cessing and handling techniques, when they substan- countries faced withthe problem of production tially reduce the nutritive value of the food, and when forthe export market,aswell asthelessde- the desired effect can be obtained by good manufactur- veloped countries who cannot afford to do their ing practices which are economically feasible. own research. CHAPTER 6
EDUCATION AND TRAINING
1.MEDICAL EDUCATION specialist studies in many different branches of medi- cine; nevertheless, it must always be conditioned by the " Medicine today covers so vast a field, its specialized branches are so varied that, in order to learn or teach it, it must be split fact that most medical students will become general up into numerous disciplines.The number of Chairs is,in practitioners. fact, continually increasing.It is impossible to overemphasize It has often been suggested that training in one of the necessity for combating any tendency to isolation - any the great scientific discipline, such as mathematics or tendency for each branch to cut itself off from the rest in an biology, is itself a liberal education.This is true, but attempt to become self -sufficient.In medical practice, obser- vation and examination, diagnosis and treatment are always the professional training of a physician requires him based on synthesis, and scientific research calls for team -work. to have a broad outlook on man in his environment, Indivisibility in medicine implies indivisibility in training. " and it is essential that the doctor should have a social, as well as a scientific, outlook. In this period of rapid In these words Professor Jacques Parisot called for a social change, a purely vocational training or a con- holistic concept of teaching in medicine in spite of the centration on the basic sciences would be quite increasing complexity of the subject.In some coun- inadequate to meet the needs of the practising physi- tries attempts have been made to make certain broad cian. divisions in both teaching and practice even in the A further principle, which has not been accepted in undergraduate years.This applies, for example, to medical schools throughout the world as widely as the Union of Soviet Socialist Republics and Poland, one would have hoped, is that undergraduate where three partially independent sections have been graduate training are to a very large extent inter- created, with the idea that the medical student should dependent.In a number of schools in Europe and be in a position near the beginning of his course to elsewhere at the present time undergraduate teaching choose one or other of these divisions as the main still includes a great deal of anatomy and surgery subject- matter of his career.The divisions in question which will never in fact be made use of by the general are general medicine, paediatrics, and public health. practitioner.Many schools also introduce a course In a number of countries, especially where the educa- in public health which is based firmly on the sciences tional system as a whole has started at a comparatively of chemistry and bacteriology and offers very little late period, the school curriculum is tending to be recognition of urgent everyday questions that arise somewhat vocational in the later years. A more in the world of men.This is a double defect, because serious difficulty arises when vocational university it not only overcrowds the undergraduate curriculum teaching follows early specialization in the school. with specialist subjects but also elbows out a great As between one medical school and another, uni- deal of teaching and practice which is of everyday formity of curriculum is neither possible nor desir- value to the general practitioner.The level at which able, but there are certain useful principles and post -graduate instruction begins, and the quality and aims that are common to most of the older groups of content of the subject- matter taught, are dependent countries.Among these are two which have been to a large extent on the reach and scope of the under- stressed in every recent report on medical education: graduate course.One of the most important features (1) undergraduate medical education should be a of post -graduate teaching is that it should begin more continuation of general education and not merely a or less where the undergraduate course left off and vocational by -way, and (2) the undergraduate curricu- so build on foundations that have already been laid. lum should be non -specialist.This curriculum is the The post -graduate teacher should not have to recap- foundation for graduates who intend to advance to itulate subjects which have been dealt with imperfectly at the undergraduate level, or to spend time in filling 1 From the Introduction to : GRUNDY, F. & MACKINTOSH, J. M. (1957) The teaching of hygiene and public health in Europe gaps that should not have been left at the earlier stage. (Wld Hlth Org. Monogr. Ser., No. 34), Geneva, p. 12 This applies to many subjects in the curriculum, but - 81 - 82 FIRST REPORT ON THE WORLD HEALTH SITUATION perhaps most of all to the teaching of preventive and -for example, encephalography and other electrical socialmedicine.The moreinclusiveand com- techniques.It was widely felt in some advancing prehensive the undergraduate course is on the subject countries that there was no longer a place for the of social medicine the greater will be the opportunities general physician.This movement was especially for scientific specialization in the post -graduate period. noticeable in the United States of America, where a It is not to be thought that these are merely aca- rapid subdivision into new specialties followed in the demic considerations.They possess today a peculiar wake of modern cardiology and neurology, and the urgency. A century ago, medicine by the nature of recent advances in surgical procedures.At the same things was practised mainly as an art.The birth time it was noticed in some countries that the concept, of scientific medicine in the second half of the 19th of social medicine as an art was being steadily super- century was due to the great discoveries in bacteriology seded by social epidemiology as a science.Epide- and later in biochemistry; this gave a strong impetus to miology, it has been said, provides the intelligence the practice of medicine, at least in hospitals, as an service of public health.'It might have been claimed exact science, so that the art of medicine was on the that this statement applied with equal force to medi- way to becoming submerged.In the course of the cine as a whole, because the picture which the clinician Second World War and the years immediately follow- sees of illness is incomplete and may well be distorted, ing, there was a steady recognizable pressure towards both in hospital and in outside specialist practice. the restoration of the medical art.This was partly The point is this: that science in the practice of medi- due to the development of the concept of social medi- cine is not confined to the laboratory and the test - cine by which the physician began to take a much tube.It has been extended far and wide by a fresh closer interest in the personal and environmental approach to epidemiology and statistics. factors in disease.About the same time, the move- There are two ways in which the advancing countries ment for health education grew in strength, and thus of today are devoting their attention to medical an important advance took place in the public and science.Many of them report that they are now professional attitude towards the promotion of health. setting up departments of health and vital statistics, By these and other means there arose a new outlook for they are realizing more and more that they cannot in favour of the social element of health and sickness. even begin to introduce public health measures to It is at least arguable that in ordinary circumstances their people unless they know the extent and depth a fair balance would have been struck between the of the problems.The second way, which nations are scientific (in the strict laboratory sense) and the social following in a more tentative manner, is through aspects of medical practice, but suddenly a new factor technical assistance in the provision of up -to -date emerged -the rapid development of radioactivity and appliances, including, for example, the complex appa- our understanding of its potential benefits and risks ratus for dealing with radioactive substances in both to mankind.This added a new and unexpected weight diagnosis and therapy. to the scientific side of the scales. It is curious to observe that, just at the moment The sharp renewal of emphasis on the physical when physical science has been clothed with new life sciences must inevitably make a difference both to the and purpose in medical practice -quite apart from the content of medical teaching and to the type of student question of the hazards connected with the manu- who seeks medicine as a career. A generation ago facture and use of radioactive substances -, a consider- it was commonly asserted that the old type of doctor able number of the reports from governments deal in -a man of wide general culture -was being replaced some detail with the training of the medical student in by a harder, more scientifically minded physician the social component of his art.Those responsible for who had little use for the art and engaged all his teaching in medical schools are realizing to an in- interest in what was being increasingly recognized as creasing extent that the product of their medical an exact science.History is repeating itself today in training should be a physician who, in addition to his many parts of the world, especially in Africa and great strictly scientific knowledge, is able to assess a social areas of South -East Asia. How far this criticism is situation, put himself in the patient's shoes and take true of the physician of today is perhaps less important his part as a member of a medico -social team in secur- than the fact that the belief has gained some accept- ing for the patient the social remedies which are so ance.It is sufficiently clear, however, that a change often the essence of a prescription for comprehensive took place in the type of student offering himself for treatment.In all countries medical care services are medicalstudiesabout the time when antibiotics increasing in complexity, and this is true of both the gained the lead in treatment, and many more exact methods of " mechanical " diagnosis were introduced 1 MORRIS, J. N. (1957) Uses of epidemiology, Edinburgh EDUCATION AND TRAINING 83 scientific and the social side.Take for example the students during their clinical years in such a way as more recent developments in theindustrialfield, to give them supervised charge of a number of families where medical practitioners are now leaders of health who are attending the department. centres and are working in teams which include nurses, The undergraduate medical curriculum has been social workers, engineers, physiotherapists and health the subject of a great deal of discussion and report. inspectors.Again, physicians in many countries carry It is difficult in the short space allotted to summarize out their professional obligations within a framework the criticisms made but the most prominent are as of organized medical care services of some complexity, follows : as in many of the Latin American states.These (1) Undergraduate teaching has been concentrated practitioners have to bring to the aid of their patients almost entirely on the patients in hospital.It is thus the benefits of social and industrial insurance schemes, artificially divorced from the circumstances in which of welfare and rehabilitation.The general practitioner the patient became ill and the environment to which of the future will no longer be concerned exclusively he will have to return on discharge. with clinical work.It has recently been said in the report of one large region that a general practitioner (2) Teaching at the bedside in many medical schools has now become a social physician. tends to be too clinical and pathological in its outlook. If we accept these circumstances of practice as Consequently the general social conditions and the relation between the patient and his environment are desirable and necessary steps to health, it follows that relatively neglected. a medical training must provide practicalsocial instruction to afford knowledge and understanding of (3) In many medical schools very little instruction a wide range of services connected with health and is given on the subjects basic to health, such as housing welfare.Since it is clear that the doctor cannot by and nutrition, economic status and social security, or himself discharge these wider responsibilities to pa- even on the organized health and medical care service tients, it follows that his training as a medical student under which the medical practitioner carries out his must give him a practical understanding of the func- daily work. tions of other members of the health team, such as (4) In spite of the gaps in teaching referred to nurses, midwives, health officers, engineers and auxi- above, the undergraduate course is often criticized on liary personnel.Even this is not enough.In addition the grounds that it is overloaded and lacking in a to his strictly professional training, the medical student coherent theme. ought to have an opportunity of gaining first -hand (5) In many schools undergraduate teaching is con- experience of the ordinary ways of living among the cerned too much with facts which have to be learned people whom he will eventually serve.Compara- almost by heart and too little with method and with tively few students have any clear idea of the living the development of sound judgement and a critical and working conditions of an industrial population. attitude of mind. To many of the students brought up in cities, the life of village folk belongs to another world; and even A considerable number of medical schools,in in their own environment many of them rarely penetrate Europe and South America especially, have recently into the domestic life of the ordinary family.Much taken these criticisms into consideration since social has already been done by governmental and teaching insurance schemes have been introduced and closely authorities to meet these defects :in some countries linked with medical practice.Increasing prominence it is a tradition that the young doctor should practise has therefore been given to social aspects of medicine. for a year or more in a relatively remote area; and in In one or two schools in North America a substantial countries where a State medical service is in operation reorientation of the whole undergraduate curriculum on a full -time basis it is not uncommon that a recent is being undertaken.The main changes are the intro- graduate is sent to a rural practice under the super- duction of one or two cultural subjects, such as vision of an experienced practitioner or the staff of philosophy and a modern language, and the reduction a health centre.Still more recently it has become a of the general course to less than five years. The course custom in certain medical courses for the clinical allows a limited amount of choice of specialty during teachers to send out the students during their under- the closing years of the curriculum.It remains to graduate years to receive practical instruction from a be seen how far the pendulum will swing in the other selected general practitioner.The out -patient depart- direction under the impetus of the growing urgencies ment of the hospital is especially valuable as a focus of the new physical sciences, the intensive search for for this activity; in some hospitals a special family more exact methods of physical diagnosis, and the service physician has been appointed to distribute endlessly elaborated methods of treatment deriving 84 FIRST REPORT ON THE WORLD HEALTH SITUATION partly from the daring advances of surgery and partly correctively, so to speak, with the results of premature from the extended use of radioactive substances. labour in the undergraduate curriculum.In post- It may well be that these changes will induce the more graduateinstructiontheoreticalteaching takesa technically minded to enter on a medical career. relatively small part.A great deal must be closely The main difficulty of medical education at the related to the actual practice of the special subject. present time, however, is not so much the content of It is therefore necessary for the post -graduate student the subjects as the crowding of the curriculum.The to spend the great part of his study in direct contact corpus of medical knowledge has become too immense with his teacher, assisting in his practical work and for any one man to comprehend.Medicine has undertaking duties of increasing complexity and res- become increasingly specialized and technical.It is ponsibility under his supervision.These considera- therefore more difficult to present to the student a tions apply with suitable adjustments toall post- picture of the patient as a whole.It is everywhere graduate subjects: surgery, midwifery, bacteriology recognized in theory, if not in practice, that there is a or public health. limit to the factual information which a student can be It is essential that the student at this senior level expected to swallow, let alone digest.In summary, should do much of his own teaching.It is for him it is very generally agreed that at present we teach the and not for the teacher to make critical notes of medical student both too much and too little: too practical exercises and to record day by day what he is, much of factual detail and too little of the broad in fact, doing.All post -graduate instruction should principles and the humanistic basis of medicine in be directed towards making the students more self - modern society. sufficient and less dependent on instructors and their The reports from various countries suggest another demonstrations.One of the most important functions difficulty that is apt to arise as medical education of post -graduate teaching is therefore to help the progresses.It is not always easy to decide which student to trust in his own independent powers of one of a number of universities ought to proceed with observation and criticism.From the medical point of plans for setting up a medical school.It is generally view hospitals and public health institutions vary agreed that universities are the proper setting for considerably even within the same country or region. medical education rather than isolated hospitals or In these circumstances one of the best methods of government institutions.The most desirable arrange- post -graduate teaching is a kind of " intern " training ment of all is when every service of a great hospital is in which the graduate goes out to learn -at first under at the disposal of medical teaching, both undergraduate the supervision of the teacher and later on his own and post -graduate.Difficulties have arisen, however, initiative -in small hospitals in the area or in district, when a number of smaller universities of more or less laboratories, for example.Similarly, post -graduate equal size and status have laid claim to medical students in public health could spend substantial teaching.It is undesirable that highly specialized staff periods of their time under the direction of a practising and the costly equipment required for teaching and health officer.A condition of success is that the research institutions should be spread too thinly in students should be sent forth singly or in very small some quite small countries where there are already numbers, unless they are, in fact, members of a team perhaps a dozen or more medical schools.Con- in which there are also non -medical students with a centration of medical teaching and practical study different background of experience. A large group of would be more effective. medical graduates working together detracts from the The essential difference between the aims of under- value of intern training, because so much depends on a graduate and post -graduate teaching is that the former close personal relationship between the health officer is intended to construct a broad foundation for any and the trainee. career in medicine and the sciences associated with it, An extension of the system of practical training while the latter should provide the framework for a which has been effected successfully in a number of specific vocation.The more specialized post -graduate countriesisto arrange for students to undertake courses should ideally presuppose a stable foundation individual surveys either of all the health services of a in general medicine.Unfortunately, in not a few small area or of a single service in a more populous universitiesthe undergraduate curriculum -say in district.This means that the student learns how to surgery or public health -is a kind of post -graduate carry out surveys by himself while he is still under course in miniature.The post -graduate teacher is tuition and the main function of teaching is to enable therefore obliged to introduce a number of subjects him to apply critical methods to his own work. A which would have been far more appropriate for the system of self instruction of this kind has been success- undergraduate period, and at the same time deal fully carried out in the School of Hygiene in Athens, EDUCATION AND TRAINING 85 and a similar method of instruction has been sucessfully very important, because the team has to adapt its employed in Yugoslavia. teaching to the true needs of the country.There is In a number of the other post -graduate sciences a always a risk that the teachers might be too remote in system of temporary training in another institution background and experience from the pupils. -perhaps under a short -term fellowship -is of great What are the main causes for this widespread value.It avoids the risk of too narrow experience in a shortage of nursing personnel ?There is no single single school or institute.In spite of what has been comprehensive answer.In some territories, generally said, it is important to point out that post -graduate backward economic conditions have made the supply teaching in any subject is and must continue to be a of trained nursing staff beyond the government's university discipline.The very fact that universities capacity.In other areas, relatively primitive customs are responsible for post -graduate training makes it clear and prejudices have hampered the introduction of that these courses are regarded, not as a form of special professional nursing and perhaps, more particularly, instruction for the conduct of a profession, but as a of midwifery in the home.In some countries other- means to expansion and enrichment of the mind to wise well advanced, the status of women has interfered makeita more perfect instrumentof inquiry, with the acceptance of the professional nurse, while knowledge and understanding. in others the limitation has been due to the low status of nursing as a career.Problems of this kind are still prevalent enough, but opposition is being steadily 2.NURSING EDUCATION, INCLUDING worn down with the growth of a more liberal attitude TRAINING IN PUBLIC HEALTH NURSING to women and a wider understanding of the need. The removal of the difficulties outlined above does The clearest issue in the great majority of replies not solve the fundamental problems.It is necessary received from governments is that there are not enough to provide training for nurses, but it is essential for nurses.More nurses are needed both for hospitals trainees to have enough education to profit by the and for the public health services.The shortage is technical training.There arestilla considerable absolute and it means that sick people in many coun- number of countries in which the educational standard tries are not receiving the skilled care which only a for admission to a training course is too low to provide trained nurse can give.Many countries are fully aware asatisfactoryqualityinthenursingprofession, of this deficiency and are making every effort within although the quantity of auxiliary nurses might be their power to overcome it.A large number of them increased. are faced with great difficulties and there are certain The returns from various countries indicate that hazards in trying to move forward too quickly.The thereisconsiderable variation in the criteria for majority of these countries need more nurses, but they admission.The direction of advance should certainly see that the need must not be met by lowering the be towards raising the admission standards progres- standards of training.There are various ways in sively to the level of a complete secondary school which the shortage can be relieved at least in part. A education.It might be desirable, moreover, for the number of countries have unfortunately no nucleus of registration authority to apply a specialtestfor trained staff which could be employed even in teaching admission, particularly in areas where no school activities.It is therefore impossible for them, as the certificate is granted.Some countries have accepted situation stands, to supply the needs of the sick or even the idea that the training school should undertake to establish simple teaching for their care or for the responsibility for its own admissions.There is much prevention of disease.In such territories it is essential to be said for this practice but the details of its appli- that trained nurses should be introduced from without cation would involve difficulty on account of the large to set up an effective scheme.The simplest and, number of nursing schools in certain countries.On in the long run, the most economical way of doing this balance it would probably be best for some academic is to secure a team of trained and experienced nurse body representing the nursing schools as a whole to teachers -a team which can handle the therapeutic set up and maintain standards of admission. and the preventive sides together and, at the same In the actual training course for nurses, certain time, deal with training in midwifery and perhaps fundamental principles have been widely accepted in certainspecial aspects such aschildcare.Itis recent years.The first of these is that nursing, like desirable but not always possible that a team of this medicine, is no longer regarded as being concerned kind should previously have worked together in an mainly with the care of the sick.It is true that the area in which standards were not particularly high. nursing student,like her counterpart the medical A knowledge of the culture and social conditions is student, has to spend, even at the present time, a large 86 FIRST REPORT ON THE WORLD HEALTH SITUATION part of her training under hospital conditions.In their experience and interest.With the closer amalga- many countriesitis accepted that great teaching mation of preventive and curative medicine, however, hospitals provide the best training.This view can be nurses of all grades are beginning to be faced with defended on the grounds that the finest teachers are teaching and administrative duties for which few of concentrated there, but the defence falls short on them have been prepared.This applies notably to two counts.First, the great majority of nurses or countries which are short of medical and other pro- doctors, as the case may be, will not in fact be employed fessional staff, and teaching schools should by no in teaching hospitals or in dealing with the conditions means neglect both therapeutic and practical instruc- and types of disease that predominate in these highly tion on the administrative side.This should not be developed units.Many of them will be distributed regarded as a temporary phenomenon.In fact, the among smaller hospitals, health centres and even little contrary is true.The administrative responsibilities rural health units.In the second place, the content of nursing are very properly tending to increase in of teaching is being changed by a new outlook on the highly developed countries and in association with function of medical care.Countries which have few well -organized medical and nursing services.The health workers or whose population is widely scattered nurse of today and tomorrow is not only a clinical ought to combine under medical care the curative and worker but also a teacher and administrator.Clearly preventive aspects as well as education inhealth. this does not apply to every nurse any more than it Nurses must therefore be prepared to deal not only applies to every doctor, engineer or public health with patients suffering from serious diseases but also worker, but itissufficiently applicable to demand with those who need simple guidance on the main- recognition in teaching courses and in the practical tenance of health and the promotion of good habits work connected with them.If this concept is not of living.It is being realized more and more that understood, nurses will tend to remain outside a service the general practitioner should be closely linked with in which they should be increasingly valuable -va- the health team, consisting of the local medical officer luable that is, in giving practical advice and assistance of health and the nurse.The nearer we come to the on nursing and public health in hospitals, in clinics, homes of the people the more important it is to intro- in health departments and in domiciliary care.More duce public health into medical care and to regard the and more countries are becoming aware of the con- nurses, like the general practitioner, as members of fidence which the people have in an experienced nurse the public health team.If these concepts of nursing in health centres and rural communities, where she are accepted, it becomes increasingly important to may well be the one professional officer on routine bring public health into the teaching curriculum for all duty.This can be seen as a progressive development nurses.It should not be thought, however, that this in countriesof many different standards -in the idea rests only on tasks which nurses in rural and highly organized islands of Scandinavia, in the remote more remote areas are expected to carry out.Under rural areas of an under -developed tropical territory, the conditions that obtain today, a nurse should be or in the small islands that are strewn over the Pacific. interested in health; she should be able to bring the At the same time it would be quite impossible, even idea of healthy living to her patients and in particular if it were desirable, to attempt to meet the nursing give positive teaching to expectant mothers, nursing shortage with fully trained nurses only.There are mothers, and, though them, to the young children. many duties which, under the supervision of a trained In the less developed countries the needs go further nurse, can be adequately carried out by auxiliary than this.Maternity nursing should be regarded as nurses.The limit to the numbers of auxiliary nurses an essential part of health care, and teaching and who can be employed satisfactorily depends directly practice should be concerned with this aspect. on the amount of supervision that can be given by Another and in some ways a more subtle change has trained nurses, and the safety margin must be watched been taking place in recent years in the functions which with care according to the kind of responsibility placed nurses are expected to perform.So long as public on the auxiliary nurse and the accessibility of the health nursing was kept in a separate compartment trained supervisor.Situations in which there are as from general work and the care of the sick, the effect many as ten auxiliary nurses to one trained nurse have was that the great majority of nurses were carrying out been reported, and in some areas this ratio is exceeded. duties which demanded largely what might be described It is essential that these auxiliaries should have re- as a clinical training.A limited number of nurses, ceived basic general education and should possess mostly of senior grades, undertook administrative some recognized degree of intelligence and adaptabil- duties or tutorial functions. A few became matrons, ity.It is no less important that they should have a nursing administrators or sister tutors, according to training in nursing duties with a strong practical bias. EDUCATION AND TRAINING 87
This instruction should be given by trained nurses auxiliary personneltocarryout varioushealth in accordance with a defined curriculum. activities under the supervision of qualified doctors. In a number of countries which have supplied Experience has shown that properly trained and super- information on the subject of nursing, it is evident vised auxiliary staff can perform useful functions in that some localnurseshave beensentabroad public health work, and their contribution to the to study in the great teaching centres.This is a health protection and promotion of a population can satisfactory arrangement for those who have been be very valuable if they are considered as members of selected for leadership or for teaching positions. a team in an organized system of health service. Even Their programme should be adapted to their particular in countries where there is a sufficient number of needs.Nurses in training who have not reached the qualified doctors, recognition has been given to the standard of selection for fellowship ought rather to use of auxiliary medical and health staff to assist the receive their instruction at some centre in the home doctors and to release them from simple routine work. country where conditions are more like those in the Auxiliary personnel are recognized by the major areas where they will ultimately practise.It is essen- branches of the medical and public health sciences- tial that training should not be divorced from the for example, medicine, dental science, environmental actual, and perhaps limited, practical work which the sanitation, pharmacy, nursing and midwifery. nurse will be expected to undertake. In the medical field the services of laboratory In the less developed areas the need for well - technicians, x -ray technicians, physiotherapists, an- trained midwives is just as great as the need for nurses. aesthetic assistants, etc., are considered indispensable, Where populations are widely scattered a very large and these types of para- medical personnel are not number of confinements take place in the home present in sufficient numbers in most countries.In without any attendants or, at most, with merely the many countries of Asia and Africa " licentiate " service of a traditional birth attendant.When there doctors and " medical assistants " have been trained is a group of trained midwives in a country of this to meet the shortage of fully qualified doctors.The kind, they naturally tend to be used in the hospital licentiate doctors usually receive two or three years services, and home confinements do not benefit less medical education than the fully qualified doctor, directly.The establishment of domiciliary service, but in a number of countries they are allowed to however, has made headway since the war and the practiseprivately.The " assistant medical practi- need for increased training has been widely accepted. tioners " trained in the Fiji Medical School are another The admission of the trained midwife to the home has type of auxiliary, of similar standing, commonly found often been slow and difficult.Some countries have in non -self -governing or trust territories in the south- had to meet their troubles half way by giving at least western Pacific.The medical assistants, who are a limited training to capable people in the elements employed in considerable numbers in Africa, are of a of midwifery, because by that means the completely lower standard than licentiate doctors, having gene- untrained midwife of the old type will be gradually rally had two to three years of technical training and eliminated.One hastomake thebestof the eight to ten years of basic education.The " feldsher " existing order of things as a springboard to further in the Union of Soviet Socialist Republics is equivalent progress. to the medical assistant in Africa.Both feldshers and medical assistants are assigned to take charge of rural health centres or dispensaries and are indispensable 3.AUXILIARY PERSONNEL IN THE HEALTH at present in the health services in the USSR, and in SERVICES many parts of Africa. During the last few years a rather unusual type of With the broadening of the concept of health, the auxiliary health worker -known as " health assistant " measures designed for the protection and promotion -has been trained in several countries.The Health of the health of a population have been greatly Assistants' School in Burma offers a two -year course increased in magnitude. A great variety of activities, to high -school students who have had ten years of from simple first -aid dressings, spraying of insecticides, general education.The course consists of 21 months and vaccinations, to the diagnosis and treatment of of classroom and laboratory teaching in basic sciences diseases and research work in the health field, have and pre -clinical, clinical and public health subjects been developed.In many countries, owing to the for a total of 850 hours.During the last three months shortage of qualified doctors, governments have found the students are sent to a rural health unit for practical it necessary, in an endeavour to fulfil their public training.After graduation they are expected to be health responsibilities,totraindifferenttypes of assigned, together with women health visitors, mid- 88 FIRST REPORT ON THE WORLD HEALTH SITUATION wives and smallpox vaccinators, as a team to work in The services of sanitary inspectors are popular in " village circles ", consisting of about 15 village tracts many Asian and African countries, and these workers with a total population ranging from 15 000 to 40 000. are considered the " front -line " health personnel, in Four courses have been given since 1951, with a total close contact with the people.If they are properly of about 440 graduates now working in the field. trained and work under the close supervision of qua- With the help of this type of personnel it is planned lified health and sanitary staff, their service to the to cover gradually all the village circles in Burma sanitation of the people's living and working environ- with some basic rural health service. ment is significant.In the Sudan, sanitary inspectors A similar type of training school has recently been are assigned to work directly under the rural or village organized in Ethiopia.This is the Public Health councils, and the general cleanliness of Sudanese vil- College in Gondar, where a three -year course is given lages is no doubt due to the activities of these workers. to graduates from secondary schools.At the end In pharmacy the auxiliary personnel are commonly of their training in the college the students are re- known as druggists or dispensers.In many countries, quired to spend one year of internship in both urban the dispensing of drugs is carried out by nurses or and rural health centres specially provided as a practical nursing aides in the health centres and dispensaries. teaching area for the college. A certain amount of The service of druggists or chemists in dispensing clinical practice in the Gondar hospital is included medicines for customers is not so well advanced in the in the intern year.In addition, the college offers a less developed countries as it is in Europe and North two -year course for public health nursing auxiliaries America. (community nurses) and a one -year course for sanitary In nursing the use of auxiliary personnel has been inspectors (sanitarians).Owing to the limited number an important phenomenon in many countries.For of graduates from secondary schools, the admissions to clinical nursing the use of nursing aides or dressers in the college are few.The first graduates were 20 health hospitalsor polyclinicsisvery common.Health officers, 15 community nurses and 12 sanitarians. visitors, who are fully trained nurses, and assistantes The training of medical assistants in the Sudan is sociales are the most usual type of trained staff in the similar to the schemes described above, except that public health services of the United Kingdom and more emphasisisgiven topractical work.The France, respectively.As the health services are further selection of students is in the first place largely from decentralized to the villages, the need for nursing among the male nurses or dressers who have worked auxiliaries becomes greater.It has been demonstrated for a number of years in one of the hospitals.The in many countries that the only possible way of ex- selection is based on personal qualities as observed tending health services to families is through this type by the senior staff of the hospital.More than eight of nursing auxiliary. years of general education and favourable recommen- The auxiliary workers in midwifery are common in dation from the hospital superintendent are among the all the less developed areas.The personnel concerned requirements for admission to the training school. range from thetraditional daistotheassistant After 18 months of classroom and laboratory training midwife. The training of localtraditionalmid- the students are assigned to hospitals to work for a wives in Asian countries has been very successful and period under the supervision of doctors before they take the improved service of these midwives has led to a up duties in the rural health centres or dispensaries. considerable reduction in infant mortality.In the In the dental service, auxiliary workers are well same way the training of illiterate midwives in the known in many countries.The school dental nurses Sudan has proved to be useful.The employment of in New Zealand, dental technicians in Europe and assistant midwives for family health service rendered dental hygienists in the United States are some familiar from sub- centres of rural health units in Egypt has examples.The service of dental nurses in preventive also been successfully demonstrated. dentistry in New Zealand has been highly appreciated The service of these types of secondary health by public health administrators all over the world. personnel isessential for the extension of health Sanitary inspectorsorsanitariansare common services to rural areas.Because of the low educational designations for environmental sanitation staff in many requirement and short period of technical training, countries.Services rendered range from the super- such staff are locally available, and economically many vision of waste and excreta disposal, food inspection, countries can afford to employ them.Furthermore, and insect control, to the contruction of simple water as they are locally recruited they are more likely to supplies, such as wells and local piped water systems. settle permanently in the rural areas. CHAPTER 7
FUTURE DEVELOPMENTS
One of the most encouraging features of the world school age, and to lay special emphasis on nutrition, health situation today is that the nations are becoming health education, and the prevention of infection. increasingly conscious of the importance of public Sound teaching of this kind in the schools is carried health as a factor in the social and economic develop- home by the children and often has the effect of ment of a country and of the need for further progress moving the parents to pay more attention to the living inthisdirection.Justasthe governments are and working environment. recognizing their growing responsibility for providing The prevention of chronic degenerative diseases has the services, so the people are becoming aware of the recently acquired a special prominence in the more need for their own participation in the endeavour to industrialized countries, partly because of the appear- build up the health of the nation.The truth has been ance of new hazards from the increasing pace of living, realized that health cannot be imposed; its promotion and partly, no doubt, on account of thesteady requires team -work within the community. Many of reduction in the killing diseases of early life.Although the more recent trends in public health administration the specific causes of many chronic conditions have not stem from this concept, and future developments will yet been determined, significant progress has been be governed by it. made in field studies on dietary and other contributing factors.Research in this subject isturning from purely laboratory studies to field observations on the 1.TRENDS IN HEALTH PROMOTION living patterns of different groups. Another advance of great significance has been made The modern concept of health as a state of physical, in the prevention of dental caries through improved mental, and social well- being, and not merely the methods of conservation.Striking benefits have been absence of disease or infirmity, has opened new secured by the introduction of water fluoridation. horizons for health workers.They are no longer Dental health services have been expanding rapidly in content with lowering the death rates, but also aim many countries, notably in the maternal and child care at reducing sickness -not only adding years to life, work undertaken by local authorities, and the use but adding life to years.In other words, there is an of auxiliary dental staff.The epidemiology of dental effort to improve the quality of human life.This can disorders and the prevention of periodontal disease is be illustrated in many ways, but steady advances can receiving closer attention.In general, the progress of be made only when the facts are known.For this dental services depends on the supply of adequately reason a number of governments are planning nation- trained staff, and, to be most economical, dental care wide surveys to secure sample morbidity figures, and should be planned as an integral part of the local the findings will exercise a great influence on future health service. measures. An interesting trend, which has spread widely Efforts to reduce infant mortality in many parts of during the last few years, has been the offer of periods the world have been successful up to a point, as a of rest or convalescence in a sanatorium or specially result of the provision of maternal and infant care equipped rest -house.Workers, school- teachers, and services; but it has been found that, in some countries, other public servants are granted leave of absence although infant lives were saved during the first twelve ranging from one week to several months, at govern- months, half of the children died before reaching the ment expense, in a well- situated coastal or mountain age of five years.The main cause was defective resort.During this period of recuperation every nutrition -particularly lack of protein.Infectious opportunity is offered for both mental and physical diseases and faulty environmental sanitation were recreation. A medical service, with doctor, nurses, contributing factors.These facts indicate the need and auxiliary staff, is provided, and special attention to extend welfare services to children of pre -school and is given to diet, rest, and graduated exercise under - 89 - 90 FIRST REPORT ON THE WORLD HEALTH SITUATION medical supervision.Arrangements for convalescent sanitation, the demand for a curative service was care are also being made to an increasing extent by pressed more vigorously than for any form of legal national and local authorities, workers' unions, and control.In these circumstances, governments were industrial firms. obliged to provide medical care to meet the immediate As a result of the striking change in the pattern of needs of the people, and so hospitals and dispensaries disease, especially since the introduction of antibiotics, had the first priority.In communities where there many of the communicable diseases have been reduced weresufficientprivategeneralpractitionersand to insignificance in the course of a generation.More arrangements for public medical care, the national attention has been given to educational services and authorities were able to establish preventive services to the provision of health care within the smaller directed both to the control of communicable diseases community.Nowadays the family is regarded as the and to the promotion of personal health.By this unit, and a domiciliary service of combined prevention means, in many countries and territories, the national and treatment is being widely introduced, with doctor, health administration was responsible for two parallel nurses, and auxiliary staff as members of each team. and more or less disconnected systems of " medical " By this means it has become possible to arrange for the and " health " services, with much greater attention follow -up of families under care, with regular observa- to the medical side.The integration of curative and tions on each individual.When a member of a preventive services in a single unit of administration family falls ill his own doctor will have ready access had developed rather slowly hitherto except in a few to a hospital or clinic and will be in a position to countries. follow up his patient at home, with the assistance of The future of public health administration moves the health team.If the disease is infectious, a close in the direction of co- ordinated planning and the liaison with the local health department will enable organization of a decentralized system.The growth the necessary steps to be taken to prevent the spread of local health centres has already demonstrated the of infection.Further, it is only through systematic value of bringing together the curative and preventive home visiting that the state of health of a population services under one roof.This development in a local can be properly and continuously recorded. Where the area linking health centres, sub -centres or dispensaries general practitioner service prevails, family records to maternity clinics to form a single health unit is can be effectively maintained; these in turn can be itself a considerable advance in co- ordination.The summarized forstatistical purposes by thelocal additional provision of ready access to a hospital and bureau of medical records and will provide the one a laboratory at a convenient centre will help to reliable source of information on morbidity. strengthen the local community services by providing It is necessary to lay considerable stress on the value specialists in both clinical and laboratory diagnosis. of medical statistics as a measure for the promotion of This will make the general practitioner's work more health, because for want of such data we do not yet attractive professionally, and so encourage young know the extent or gravity of the problem of disease medical graduates to take up combined medical and in the less advanced countries.Sickness and disability preventive work as a career.Recent experience in may have a far more profound effect than is at present the Union of Soviet Socialist Republics and elsewhere realized, and it may well be that through the lack has shown that government action in promoting and of accurate information on morbidity an intolerable protecting the health of the people and in co- ordinating burden of suffering, economic loss, and social misery research, education and practice in the medical sciences is imposed on the community. has an educative influence of great strength on the people and the profession. Since the National Health Service came into being 2. DEVELOPMENTS IN ADMINISTRATION in the United Kingdom, it has been demonstrated that complete medical service can be provided by a The term " public health administration " has been system under which the financial resources of health variously interpreted.Traditionally, it covered only insurance are combined with those of the regular matters of control and regulation of environmental budget.Both Chile and Sweden have recently suc- services and the protection of the public against com- ceeded in extending social insurance schemes to cover municable disease.At that stage of development, comprehensive medical services for the population. sanitary legislation was the most important function In this way it can be seen that public health adminis- of administration both centrally and locally.In tration has gradually evolved during the past half - countries where there were extremely few doctors, century from a service fulfilling purely regulative a high percentage of illiteracy, and practically no functions and environmental control to a science of FUTURE DEVELOPMENTS 91 management through which modern medical know- social and economic system, and its progress in these ledge is being transformed into practical measures for countries has been remarkable. Among the many protecting and promoting personal and community reasons for this rapid advance is the co- ordinated health.One of the most important future responsi- planning of medical education, research, and practice. bilities of administration will be to bridge the gap One of the essential preparations for long -term pro- between the knowledge gained from the medical grammes is the health survey.Many governments are sciences and the practical application of that know- now carrying out such surveys periodically in order ledge.It has been demonstrated clearly that one of to assess their needs.Experience has shown that the the most effective means of doing this is by organizing important thing is to determine priorities and to plan community work with the people, thus winning their the services on a permanent basis within the economic active participation.To fulfil these responsibilities, resources of the country.It is true that the health many obstacles will have to be overcome.The task needs of a country may not be fully met at first is not easy, but recent advances in various parts of because of limited resources, but the plans should be the world indicate that the essential steps are now prepared on the principle of progress to a complete being taken in administrative planning.Pilot studies scheme.Similarly, the standard of services rendered and field demonstration programmes help to convince may be relatively low during the initial period on governments and their people that community services account of the poor educational and economic condi- can be undertaken as part of a combined educational tions of the country; nevertheless, plans should be made plan. on the principle that these standards will progressively improve.It is best to draw up a plan which can be gradually unfolded as conditions permit. 3.LONG -RANGE PLANNING
The planning of long -range health programmes is a 4. SHORT -TERM INDEPENDENT PROGRAMMES new activity which will ultimately become part of the normal function of national governments. The Indian Programmes for individual health projects of short and Sudanese Governments, for example, have re- duration are becoming popular, especially where inter- cently started their second five -year plans for social national or bilateral assistance is available.In general, and economic development.The first five -year pro- these programmes are directed to the control or eradi- grammes have been fulfilled;the second contain cation of specific communicable diseases, such as yaws important health proposals.In Egypt, the former or malaria.Isolated independent programmes of a Council of Public Welfare Services initiated a system specialkind -for fielddemonstrationorlimited of long -term planning of all its public services, and the investigations -also exist in a few countries.These first five -year plan of " combined centres " for rural short -term projects, unless they are connected with areas has now been carried out.The Ministry of long -range national programmes and are associated Health of Indonesia has set up a special planning with permanent health services, usually have only a commission and has worked out a detailed long -range temporary or limited effect on the health situation of a programme for various types of preventive service. country, even if they are successfully carried out. In other countries, such as Ethiopia and Afghanistan, On the other hand, short -term independent pro- organizations have been established by the central grammes as part of a long -range plan are useful in authorities to undertake long -range planning.South many instances.Where financial resources are re- American interest in the subject was evidenced by the stricted or there is an unusual shortage of medical and technical discussions which took place at a recent para- medical personnel, only programmes of a limited meeting of the Council of the Pan American Sanitary scope, perhaps on a yearly basis, may be feasible. Bureau /Regional Committee of WHO. In many countries the first step has been to provide Long -range planning was first begun mainly as a a simple medical care service for small communities means of promoting economic development, as, for through the employment of medical auxiliaries. This example, in the USSR following the revolution and has been followed up by a scheme of in- service training in a number of other countries after the Second World of the existing staff with the object of introducing War.Since then experience has been gained in preventive work in addition to the usual medical and planning for the orderly progress of countries, includ- nursing care.For this purpose, qualified medical ing their economic, social and cultural advancement. staff are trained and appointed to supervise the work The development of health work in a number of of the auxiliaries, and, in this way, a higher standard countries has been planned as an essential part of the of community care can be attained.For example, a 92 FIRST REPORT ON THE WORLD HEALTH SITUATION plan to control the most prevalent diseases in an area, attention to the need for rural health services many together with the provision of essential laboratory years ago, by initiating rural conferences in Europe services, may be launched.If the individual pro- and the Far East.The Second World War paralysed grammes are properly co- ordinated and followed up, this movement, and the rebirth of rural health services substantial advances will be achieved.This process has only recently taken place. has been observed in a few countries, and it may well This revival of interest was set going by the public become a pattern for the future in many of the de- health professions, and the movement has become veloping countries of the world. widespread, as is demonstrated by both national and international conferences on the subject and by the initiation of actual centres.Health administrators 5.COMMUNICABLE DISEASE CONTROL are deeply concerned with the lack of provision for Many of the communicable diseases are still pre- rural areas caused by great differences in economic valent in most tropical and subtropical countries. and social development between rural and urban communities.Moreover, problems of urban growth Diseases for which there are known reliable methods have been created by the rapid influx of rural popula- of prevention and control -such as smallpox and yaws tions into the towns.If it is not quickly controlled, -are still threatening many countries today.Where this situation will create new forms of social unrest. these diseases exist in either endemic or epidemic form, it has been clearly shown that, when the governments In spite of great difficulties in securing financial were firmly determined to initiate a programme of appropriations for rural health work, a good beginning eradication and organized their resources to carry it has been made in promoting the essential services out, smallpox and yaws virtually disappeared in a for small communities.In addition, the national authorities have used various means of encouraging short period of time.It is evident, therefore, that the persistence of these two diseases is not due to lack young medical graduates to take up at least temporary of technical knowledge or experience but rather to a appointments in rural districts before they settle finally in their chosen practice.In this way it has been want of determination and organized effort in applying possible, where the rural population constitutes a high that knowledge. During recent years, through international collabo- proportion of the total, to start a series of rural units ration, organized campaigns have been worked out in which both curative and preventive work is carried out.As a means of providing technical assistance to control the spread of quarantinablediseases. and supervision, the value of a provincial or regional Improvements in the preparation of smallpox vaccine and new preventive techniques for dealing with a service with the necessary technical establishments, number of the other diseases have now been achieved. such as hospitals and laboratories, has been well During the next few years it is likely that steps will demonstrated.Under this system hospitals with at least a limited number of specialist services are made be taken to devise co- ordinated schemes and well - available to the rural people, and the cost is kept planned timetables for eradicating a number of these of the country. distressing, but preventable, conditions.It has also within the economic possibilities Further extension depends on financial considerations. been demonstrated that any programme of eradication In many rural areas the health service has been the can be carried out more efficiently and economically if it is properly fitted into the general health service spearhead in the control of the commoner communic- able diseases, and the provision of these personal of the country. medical services has cleared the way for economic and social development.In many parts of the world the 6. RURAL HEALTH DEVELOPMENT health advances have in fact improved the economic state of the areas by eliminating the wasteful diseases The concentration of the medical profession in urban and bringing greater vigour to the people. areas and the predominance of health services in cities have deprived country dwellers of modern services in many districts.With the increase in industrial deve- 7.SUPPLY OF MEDICAL MANPOWER lopment without proper economic and social planning the rural population -which constitutes about three - The insufficiency of medical and auxiliary personnel, quarters of the world total -is further deprived of both qualitative and quantitative, has been a serious subsistence and its standard of living in some countries obstacle to the extension of health services in a large is deplorable, in spite of the fact that it produces the number of countries.The situation has been tempo- world's food.The League of Nations first called rarily eased by the training and use of auxiliary work- FUTURE DEVELOPMENTS 93 ers, but this does not solve the main problem.In a various economic, educational,health and social few countries only, through the effective co- ordination measures aimed at the general improvement of rural of medical education with health programmes, con- communities with the active participation of the popu- siderable advances have been made in speeding up the lation.Health, as an essential element of this develop- production of the right type of medical manpower. ment, has been closely associated with it.In countries Many governments are well aware of this problem, such as India, Burma, Iran, the Philippines and Egypt, and more effective plans for preparing the right where efforts to develop rural communities are being numbers and categories of medical men and women made, a health service has always been considered as a will have to be worked out.National health adminis- prerequisite, and the training of health workers for trators will have to take part in formulating education rural areas has been the fundamental step necessary policy on medical and allied subjects and in the to realize such a programme.The Government of detailed planning of curricula. The producers and the India has included in its second five -year plan the consumers will have to consult each other more establishment of 3000 local health units, most of closely in working out both national and local training them situated in the community development areas. schemes, as a great deal of economy can be secured The plans for community development differ in by a joint effort.Both national and international emphasis according to the country.In come coun- leadership are urgently called for to meet the needs of tries emphasis is laid on mass education as an initial education and training. step.In others, agricultural improvement has been used as an incentive to bring about co- ordinated action. In a few instances, through health services, the villagers 8. IMPROVEMENT OF LIVING have been activated to demonstrate self -help by build- AND WORKING ENVIRONMENT ing maternal and child health centres and by contribut- The improvement of environmental sanitation has ing labour for constructing water -supply systems. A been largely dependent, in the past, on industrial and co- ordinated, multi -purpose approach to community urban development.This has led to the belief that development in rural areas, involving all the essential any large -scale environmental sanitation programme elements, such as education, agricultural extension, will have to wait until the economic situation of an health and welfare services, has recently been worked area is ready for it.This conservative attitude has out and steps have been taken in a number of countries to start these programmes.Whether the countries in caused delay in action in many advancing communities. Governments are, however, becoming increasingly fact manage to achieve economic and social progress willing to accept the importance of improving the in the rural communities depends on the position of living and working environment of their people. the rural economy in relation to that of the urban Most of the technical facts about the provision of a economy, and on the social status of the rural popula- safe water supply, the disposal of sewage and the tion in managing its own affairs.Experience has health aspects of housing are already known, and with shown that social evolution will take its course if the the knowledge and experience now acquired it should people have the opportunity to learn modern ways not be difficult to make substantial progress. and to exercise their ability in adjusting and improving their own living conditions. From the financial aspect, if the long -term view is taken, the cost of carrying out well- designed environ- mental schemes will be covered by the economic benefits derived from reduced death and sickness rates. 10. HEALTH ASPECTS OF RADIATION In preparation for all these costly developments, the education of the public and local authorities is an The development of atomic energy for peaceful purposes is fairly well advanced in only a few coun- important factor.Encouraging signsarealready evident in many parts of the world -even in rural areas, tries; and, in these, the use of nuclear energy, as well where the public is demanding a healthier living and as of the radioactive by- products, is by no means as working environment and is, in some instances, taking widespread as it may be expected to become during the initiative through its own active participation. the next few years.An increasing number of coun- triesare,at the present time, developing nuclear energy projects, and a still larger number are planning 9.PLANS FOR COMMUNITY DEVELOPMENT activities for the near future.These schemes will raise many public health problems, especially if they Community development has recently been designed are hastily conceived and put into operation without to prepare the way for a co- ordinated approach to fundamental studies being made in advance. 94 FIRST REPORT ON THE WORLD HEALTH SITUATION
In the United States of America and the United has become greater.Opportunities for practical obser- Kingdom -two of the countries where atomic energy vations and field studies have increased, and this has programmesarewelladvanced -a considerable stimulated a number of questions in the minds of many amount of attention has been given to the medical public health administrators.What are the most aspects of working with sources of radiation, includ- effective measures ?How can services for the protec- ing nuclear reactors and radioactive isotopes.Pro- tion and promotion of the health of the people be grammes of health protection have grown up side by accurately assessed, and what are the means for side with the technological advances in physics, chem- measuring the health of a nation ?To what extent istry and engineering. A great deal of attention has is the health of the people dependent on the general also been given to waste disposal and the possibilities level of education and the active participation of the of environmental contamination. people in community work ?What is the best way to While, in the past, most of the activities in this field bring about successful co- ordination in planning eco- have been undertaken within the atomic energy orga- nomic, cultural, health, and other social programmes ? nizations themselves, or in close association with What categories of medical and health personnel are them, in recent years there has been an increasing needed to carry out an effective programme, and how tendency for health authorities to formulate radiation should they be trained ?What are the gaps in our control programmes at both the local and the national knowledge and experience and in what way can health level.The development of radiation control pro- workers contribute to filling these gaps ?What is grammes within the framework of health organizations the most economical way of financing medical ser- is based on several factors.The health authorities vices ?What should be the role of private general realize their immense responsibilities in this area and practitioners in a national programme ? How can the the serious problems which may arise if adequate interestsof social insurance and national health planning is not undertaken in good time.Many administration converge to serve the interest of the radiation health activities lie more appropriately with population as a whole ? the national and local health authorities than with Public health work has grown in the past by meeting atomic energy agencies, where there is at least the emergencies and problems as they arose, and there possibility of a biased approach to the health problems has been little opportunity for public health workers involved. We have not enough information about to plan an orderly development of their services.The the procedure adopted in the Union of Soviet Socialist history is too short, and with two periods of world war Republics, but in other countries that have made intervening in the last half -century, no opportunities great advances in the field of atomic energy the arose for careful observation and intensive study of technical authorities are entrusted with the safety of some of the questions referred to above.The progress their own operations and the protection of the public of clinical medicine, on the other hand, has been very in their immediate neighbourhood.The health auth- much eased by the establishment of hospitals and orities, on the other hand, have a general respon- laboratory facilities. For careful observation and study sibility to protect the people against the possibly of some of the public health problems, the establish- harmful effects of radiation. ment of field studies and demonstration areas has now The health ministries of countries which are just become essential. beginning atomic projects or enlarging their activities During the last few years pilot studies of local health in radiation are in a good position to gain from the services have been initiated in five areas -the United experience of their counterparts in countries where Kingdom, India, the Netherlands, Puerto Rico and this kind of work has been going on for some years. Sweden.Along with these studies family surveys on One of the greatest difficulties is to obtain a sufficient a sampling basis have also begun in four of the coun- number of trained staff.This need, which is now tries mentioned.The national authorities concerned widely recognized, has led to an expansion of training are very much interested in the studies and have facilities in a number of countries, and the opportu- assigned local officers to take charge of the work. nities in both health protection and research are These pilot studies are designed to analyse the develop- improving steadily. ment of local health services in relation to the eco- nomic, cultural and social development in the areas during the past twenty years or so, and to assess the 11.FIELD RESEARCH AND INVESTIGATION state of health of the local inhabitants within their living and working conditions.The findings of the With the rapid extension of health services during pilot studies, because of the differences in social and the past ten years, the potentiality for further progress economic backgrounds as well as in the pattern of local FUTURE DEVELOPMENTS 95 health services, will be of interest not only to public promotion and protection of health is of value to all ".1 health administrators, but also to health statisticians Governments are becoming increasingly aware of the in connexion with the morbidity conditions in these need for fuller international collaboration.Mutual areas. From the research standpoint this method of benefit has been obtained through the exchange of approach is unique in that it deals with the actual information and experience,aswellasthrough living medium of human community rather than any technical assistance. artificial media, and further progress in public health The general trend is towards fuller collaboration work will depend much on the extension of such field betweennationsinmedicaleducation,medical studies. research, and public health training, on a regional The use of demonstration areas to co- ordinate health basis.The establishment of the Gothenberg School services with economic and social development is of Public Health in Sweden, which serves the Scan- another new approach.As healthisintimately dinavian countries, and the founding of the Institute of associated with the way of life of a people, the mere Nutrition for Central America and Panama, are transfer of a pattern of health service from one country examples of such an effort. to another, without an attempt to fit it to the local Collaboration has also found expression in the cultural, economic and social conditions, will not be successful control of the six quarantinable diseases and successful.In the last few years two demonstration in the endeavour to eradicate malaria, while, in yet areas were established -one in Egypt and the other in another domain, international action in creating fellow- El Salvador.Various forms of local service have been ships for the training of public health personnel plays demonstrated; the active participation of local in- an important part in fostering mutual understanding habitants has been enlisted, and co- ordination of the and in strengthening national health services. various community measures has been worked out. With a spirit of partnership prevailing in the The governments concerned are deeply interested in planning and organization of international work to the results of these demonstrations and it is expected improve the world health situation, each country will that more projects will be started before long. benefit from collaboration.Preventive medicine is entering a new era -the era of the universal participa- tion of the people -and thereisgreat scope for 12.INTERNATIONAL COLLABORATION development.But the essential condition for any advance in health work is a modest and co- operative With the rapid means of transport and the con- approach, for every country has both something to venience of modern travel, it has become more and learn and something to teach.Indeed, this prin- more evident that " unequal development in different ciple of give- and -take is the very keystone of future countries in the promotion of health and control of progress. disease, especially communicable disease, is a common danger " and " the achievement of any State in the 1 Constitution of the World Health Organization
PartII
COUNTRY REVIEWS NOTE
Part II of this volume contains the reports submitted by governments and all amend- ments subsequently received. 1Since the present report covers, as indicated in resolution WHA9.27, the period 1954 to the end of 1956, it has not been possible to take into account all the changes in the political status of countries and territories that have taken place since the end of this period.Therefore such changes, and the modifications in terminology they would involve, may not be reflected in this volume. In one or two instances the amendments submitted by governments to the reports on the health situation in their countries were not strictly confined to the period under review, but it was considered unnecessary to apply too rigid a deadline to material that might enhance the significance of the report. The country reviews have been grouped in the six regions delineated by the World Health Assembly and arranged in alphabetical order under the relevant regional head. To facilitate reference, an alphabetical list of all countries and territories is included at the end of the volume. In order to make data readily comparable the metric system has been used throughout. For the same reason US dollar equivalents have been given for amounts in other currencies, calculated at the rate of exchange prevailing on 31 December 1956 (unless otherwise stated). To avoid repetition the denominators of the rates pertaining to births, deaths, infant mortality, and maternal motality have been omitted.It should be understood that these rates are expressed throughout in the following terms: Birth rate :per 1000 population Death rate: per 1000 population Infant mortality rate : per 1000 live births Maternal mortality rate: per 1000 total births.
See Note, page II.
- 98 - AFRICAN REGION FIG. 6. AFRICAN REGION
MADAGASCAR SOUTH...... -WES
:Windhoek MAURITIUS Port Louis REUNION St Denis ANGOLA
The Portuguese Province of Angola is situated on the west areas as councils or boroughs; the health units cover coast of Africa between latitudes 4° and 18° south and longi- smaller administrative areas; the health centres are tudes 12° and 24° east.It is bounded on the north by French Equatorial Africa and the Belgian Congo, on the east by the established in the more populated and more developed Belgian Congo and Rhodesia, on the south by South -West localities; regional hospitals are in district capitals; Africa, and on the west by the Atlantic Ocean.Its area is and the two central hospitals, one in Luanda and 1 246 700 square kilometres.The total population in 1956 was one in New Lisbon, serve the two towns with the estimated at 4 408 000. largest population. The capitalof AngolaisLuanda.For administrative purposes, the Province is divided into 13 districts, each under a District health services are in the charge of one governor, and the districts are subdivided into councils and or more medical officers, assisted by the necessary boroughs. A Governor -General is responsible for the govern- nursing staff; the health units are run by one or ment of the Province as a whole. more male nurses who work under the direct super- The territory is mainly agricultural; it produces coffee, sisal, palm -oil, tobacco, rice, sugar -cane, maize, tropical fruits, and vision of the district medical officer. European fruitsinthe uplands.Fishingisan important Voluntary organizations,religious missions and occupation along the 1600 kilometres of sea -coast, and there is industrial undertakings assist the Government in the a well -developed industry for the drying and preserving of fish medical and health care of the population, and and preparation of fish oil and meal.The subsoil is rich in diamonds, which are one of the Province's most important provide the following facilities : 62 hospitals, 248 health exports.Copper, iron, manganese, gold, silver and coal are units, 272 medical aid posts, six nursing homes, 16 ma- also produced. ternity centres, eight leprosaria, 43 ambulances and 13 dispensaries.The Angola Diamond Company is Health responsible for all the health services in the borough The health services were reorganized on the basis of Chitato (Lumda), where its employees are working; of a Decree promulgated in 1945 which related to the it provides constantly increasing facilities for medical ,general structure of health services in the Portuguese care, which at present consist of six hospitals, four ma- overseas provinces. The highest authority is the Health ternity centres, 64 medical aid posts and four ambul- Directorate, which exercises technical and admini- ances.Thesearestaffed by 14 physicians, two strative control over all the State health services and pharmacists, 23 male nurses, 33 female nurses and also supervises the work of voluntary. organizations auxiliary midwives, 117 assistant nurses, one European in the field of health.Apart from a General Secre- midwife,onelaboratoryworker and pharmacy tariat in charge of personnel matters, the Health assistant. Directorate comprises three departments: medical, The following table shows the number of medical pharmaceutical and administrative. and para -medical personnel in Angola in 1956, in The central services attached to the Health Direc- both government and non -government service: torate are as follows: inspection of pharmacies; public Government Private Total health and control of epidemic and endemic diseases Physicians 180 90 270 (particularlymalaria,leprosyandtuberculosis); Nurses and auxiliaries 438 404 842 trypanosomiasis control; medical care of African Midwives 29 59 88 workers (the Nutrition Commission is attached to Pharmacists 18 10 28 sanitary thisservice); maternal and child health; Total 665 563 1228 control (air, land and sea); health statistics; and general medical and hospital services. During the period under review, the proportion of The Health Directorateisresponsible for the the total government budget devoted to the adminis- technical and administrative direction of five health tration of the health services was as follows : in 1954, regions under the charge of an inspector; 86 district 74 500 000 Escudos (US $2 573 402), or 4.7 per cent. health services; 188 health units; 76 health centres of the total government budget; in 1956, 75 500 000 with or without a small hospital or nursing station; Escudos (US $2 607 945), or 5 per cent. of the total. 32 maternity centres; six tuberculosis control centres; These percentages refer exclusively to the amounts seven infant welfare centres; five leprosaria; 13 regional set aside for running the services; costs of construc- hospitals and two central hospitals.These establish- tion and equipment of hospitals and other establish- ments are distributed throughout the territory accord- ments are met from another fund, from which ing to the administrative divisions to which they 150 000 000Escudos (US $5 181 347)werespent belong: the district health services cover the same between 1954 and 1956.If this is taken into account,
-- 101 - 102 FIRST REPORT ON THE WORLD HEALTH SITUATION the percentage of the total budget devoted to health units for mass miniature x -ray examinations in addi- is increased to 8 per cent. tion to the existing facilities. The following facilities exist in Angola for training A survey of deficiency diseases was made in 1954 -55, para- medical personnel: which made it possible to identify the most prevalent (1) In Luanda, there is a regular nursing course forms of these diseases.Changes in diet have been of two years' duration followed by one year's hospital introduced, and the number of cases has decreased work; candidates for admission must have completed appreciably. the first half of secondary education. Particular mention should be made of the work (2) Elementary courses in nursing are given in the done by the trypanosomiasis control service and the district capitals; they are of two years' duration, "Pentamidine Team " already referred to.Control andcandidatesmusthavecompletedprimary operations are conducted through 83 health centres education. and by five mobile units, and the number of diagnosed cases has fallen from 997 in 1954, and 1015 in 1955, (3) Courses for auxiliary nurse -midwives are of to 418 in 1956.Recent surveys of the population the same duration as those for auxiliary nurses, and have resulted in more -accurate vital statistics.The candidates must also have completed primary edu- following table shows the position: cation. 1954 1955 1956 During the period under review, both the pre- Birth rate 32.5 33.6 36.0 ventive and the curative aspects of the health services Death rate 13.9 14.9 15.7 have increased in scope; the provision of services Rate of increase 18.6 18.7 20.3 has been widened, special units have been set up for the treatment and prevention of certain diseases, the Many factors are contributing to the rapid progress number of maternal and child health centres has being made in urban development and environmental grown, and theactivitiesof the trypanosomiasis sanitation, not only in the large cities but also in control service and the " Pentamidine Team " have the smaller towns and villages.The population of developedintoa masscontrolcampaign.The the existing urban centres has increased, and new results of this campaign are reflected in the statistics, areas have been developed; municipal and govern- which show an increase in the number of persons ment technical services have been organized; progress treated and a decrease in the number of new cases has been made in housing, water supplies, drainage recorded as compared with previous years. and other environmental facilities; and the economic Health surveys have been carried out by the prosperity which has come to the Province has Endemic Diseases Survey and Control Service with brought an improved standard of living to the majo- the object of determining the over -all incidence and rity of the population. distribution of certain endemic diseases, such as During the past three years, 403 permanent camps yellow fever,malaria and itsvectors,bilharziasis have been built for workers in government and and its intermediate hosts, and onchocerciasis (includ- private agricultural undertakings.On the outskirts ing the distribution of Simulium). of the large towns blocks of flats have been built Between 1952 and1954,theLeprosy Survey to house 843 workers and their families.These services found 4000 cases of leprosy in the Bié district, developments, which have been accompanied by and in 1954 and 1955 they surveyed the area of large -scale campaigns for the control of flies and Huila, Malange and Luanda. mosquitos, have improved conditions in vast areas There are at present six tuberculosis dispensaries, of the territory, both urban and rural, and have con- and a recently organized tuberculosis control service tributed to raising the level of health of the African is about to enter a more active phase, using mobile population.
BASUTOLAND
Basutoland lies between latitudes 28° and 30° south, and Drakensberg chain and is elevated and rugged, the altitude longitudes 27° and 29° east.It forms an enclave within the rising from about 1550 to 3100 metres above sea level.The Union of South Africa, bounded on the north and west by the average rainfallisapproximately 70 centimetres annually. Orange Free State, on the east by Natal and on the south by Serious droughts are rare, but not unknown.Its area is about Cape Province.The territory is well watered and the climate 30 344 square kilometres, and the population, according to the is good. Most of the country is occupied by part of the great 1956 census, consists of 638 857 Africans, 1926 Europeans, AFRICAN REGION 103
247 Asiatics and 644 mixed races.The Basuto are a homo- There is a government hospital in each district, with geneous people; they represent the southernmost concentration one or more medical officers and a trained nursing of the Sotho -speaking tribes of the Southern Bantu and are related to the Bechuana. staff.Each hospital has an ante -natal and child The territory is governed by a Resident Commissioner, under welfare clinic, and tuberculosis, maternity, children's the direction of the High Commissioner for Basutoland, the and isolation wards are being provided.There is Bechuanaland Protectorate and Swaziland, working in close a mental detention centre under the charge of an co- operation with the Paramount Chief.For administrative purposes the territory is divided into nine districts, each under African medical officer, but this is to be replaced by a a District Commissioner, which are further subdivided into mental hospital, which is to be constructed in the " wards " and smaller areas, presided over by hereditary chiefs immediate future. and sub -chiefs, who are responsible to the Paramount Chief In addition to the Director of Medical Services, the on all questions of local law and custom.These chiefs, parti- European medical staff consists of one medical officer cularly the headmen, are the authorities with whom the ordinary people deal in their daily affairs.They owe allegiance, through of health, 14 medical officers and one assistant medical their immediate superiors, to the Paramount Chief, though in officer, one senior matron, one sister tutor, three practice, in matters not entirely concerned with Basuto law and nursing sisters in charge, ten nursing sisters, one custom, they normally work with their relevant district com- pharmacist, one health inspector, one male mental missioners.District Councils were established in1943 as nurse and one superintendent of the leprosy settle- advisory and consultative bodies in all districts. The principal occupations of the Basuto are agriculture and ment.The African staff comprises five medical offi- stock farming.Mineral prospects are poor; there are no cers, one assistant health inspector, six health assis- factories and no industries other than two small printing works tants, one sanitation assistant, 31 dispensers, four pupil operated by missionary societies.The principal crops are dispensers, seven ward sisters, 45 nurses, 27 student maize, sorghum, wheat, peas and beans, and some barley and oats, the chief exports being wool, mohair and livestock.The nurses and midwives, 112 ward attendants, 11 mental Basuto have a strong predilection for maize as the main article centre attendants, nine leprosy and health and welfare of their diet, which is thought to be responsible for several of inspectors, one laboratory assistant, and 120 other the deficiency diseases. A continuing excess of imports over African staff.The medical staff of the missionary exports has resulted from the export of labour to mines, indus- institutionsis medicalofficers, tries and farms in the Union of South Africa.For example, composed of six 39 402 Basuto were recorded as being in employment in mines nine trained European nurses, eight African nurses, alone on 31 December 1956. and 79 other African personnel.It is estimated that Soil erosion and exhaustion are serious problems in Basuto- there is one doctor per 18 203 population and one land and a large proportion of development expenditure is hospital bed per 742 population. devoted to their solution. African education is largely in the hands of three main missions Existing hospital facilities include nine government - under the direction of the Education Department. controlled hospitals with 485 beds and four mission Community development and welfare have taken shape hospitals with 276 beds.In addition,there are according to the indigenous pattern of Basuto society.Basuto 24 maternity and child welfare clinics, 21 venereal law and custom provide solutions for social problems, assisted by the Administration where necessary. A number of halls disease clinics, four health centres, three mountain have been established at district headquarters for community dispensaries, 52 out -patients clinics, one leprosarium, activities with the help of a Basuto Committee at each focal one mental health centre and nine x -ray installations. point. A Basutoland Homemakers' Association is responsible Of the nine government hospitals, four are staffed by for over 150 clubs and gives advice and help on such matters European nursing sisters with subordinate African as education, domestic arts, hygiene and child care and feeding. Development projects include schemes for the improvement personnel, while five are staffed by trained African of agriculture, and an extensive survey for the supply of water nurses and auxiliary African personnel.The leprosy to the western border. settlement in the Maseru district, with 54 beds, is under the charge of a medical superintendent assisted by a ward sister and two trained African nurses.There Health is a children's home within the grounds of Emmanuel Mission (Seventh Day Adventist)intheLeribe The Medical Department isunder a Medical district, for infants born to mothers who are leprosy Director with headquarters at Maseru.Owing to the patients in the settlement.This home is under the nature of the terrain and poor communications in the care of a former matron, who gives her services on mountain areas, rural health work is not easy, and a voluntary basis. much travel has to be done on foot or horseback. The principal diseases encountered are venereal There is one medical officer of health and one qualified diseases, chronic rheumatism, infections of the res- European health inspector on the staff of the Medical piratory tract and diseases due to nutritional deficiency. Department, mainly concerned with sanitation and Diphtheria, typhoid fever, measles and whooping- hygiene measures and the control of infectious diseases. cough are endemic.Basutoland is almost uniquely 104 FIRST REPORT ON THE WORLD HEALTH SITUATION free from tropical or subtropical diseases and the surgical nurses, and six passing the final examination communicable and general diseases are those found for midwives.Six pupil midwives and four student in temperate climates.Two of the major health nurses passed the final examination set by the Com- problems are tuberculosis and nutritional and defi- mittee.Queen Elizabeth II Hospital is also the centre ciency diseases, manifested by outbreaks of pellagra for training health assistants.Dispenser- anaesthetists and kwashiorkor. A study of indigenous foods and are trained by the pharmacist under a system of their nutritive value is being undertaken with a view apprenticeship to senior dispensers. to the improvement of the nutritional status by a Of five Africans who received medical training over- variety of means.Smallpox and typhus fever are seas under the Colonial Development Scheme, three kept under control by appropriate measures. are in government service.In addition, nine Basuto There is no medical school in the territory and the are at present studying medicine in the Union of new Maseru hospital -the Queen Elizabeth II Hos- South Africa or the United Kingdom with assistance pital-is to be the main centre for the training of from public funds. African nurses, midwives and auxiliary staff.There There are no laboratory facilities in the territory, are two grades: student nurses for the Basutoland but the Department has an agreement with the South Executive Nursing Committee's certificate, and those African Institute for Medical Research for the perform- for the certificate granted by the High Commission ance of pathological and other investigations. Territories Nursing Council.In 1957 there were Medical research has been limited to the study of 27 student nurses and midwives in training, two passing nutritional deficiency diseases by members of the the final examination of the Council for medical and Medical Department.
BECHUANALAND PROTECTORATE
Bechuanaland lies between 18° and 27° south and 20° and 29° to the transfer of the immediate control of schools, in areas east, partly within the tropics, partly outside.It is bounded where there is an adequate social organization, from mission on the south and east by the Cape and Transvaal Provinces of or government agencies to the tribes.No higher education the Union of South Africa, on the north and north -east by is provided in the Protectorate, but a small number of students Caprivi Strip, Northern Rhodesia and Southern Rhodesia and attend universities in the United Kingdom, Basutoland and on the west by South -West Africa.It has an area of about the Union of South Africa. 712 200 square kilometres and a dry climate, healthy for the Social problems are satisfactorily solved according to long - most part of the year.Over 95 per cent. of the population established tribal custom, strengthened by official social welfare is engaged in stock -raising.The lack of moisture hampers schemes.Community centres and clubs have been established agriculture. at several of the larger settlements and funds have been raised, The estimated population in 1956 was 328 335.The great through tribal initiative, for the building of dispensaries. majority of the people live in the eastern and northern- western A Colonial Development and Welfare Fund allocation to part of the country; about one -half live in villages of 1000 or Bechuanaland totalling £980 000 (US $2 744 000), together with more inhabitants, although many of these spend a large part of an unexpended balance of £272 083 (US $761 832), will be their time at outlying cattle stations. devoted to schemes for the improvement of agriculture, water The Protectorate is divided for administrative purposes into development, veterinary and disease control projects, education 12 districts, each under a District Commissioner." Indirect and medical services. rule " by tribal administrations has been formally established, and the rights and powers of African Authorities have been defined.Each African Administration has a treasury, of which Health the main revenue is a proportion of the native tax allotted by The Medical Department of Bechuanaland is under the Government. As the basis of the territory's economy, stock -raising and the the charge of a Director of Medical Services, who is export of stock and meat and animal by- products are extremely responsible to the Resident Commissioner and advises important.The staple subsistence foodstuffs produced com- him on health matters and policy.There are six gov- prise sorghum, pulses and beans, millet and maize.There are ernment district hospitals, with 344 beds, including a no significant manufacturing industries.The main mineral industry is the mining of chrysolite asbestos.Some mining mental hospital of 24 beds, each in charge of a medical of gold, silver, kyanite and manganese has been started, and officer, and seven mission hospitals (203 beds), for the Government's policy is to encourage the search for other which there are four medical officers and 13 nursing minerals such as copper and coal, in order to free the country sisters.The staff of health inspectors consists of two from its present almost total dependence on the cattle industry. European inspectors, five local health inspectors and The educational system is determined by geographical and other factors, but is hampered by the seasonal migrations to fivehealth assistants.All the hospitals are well the agricultural lands.The policy of " indirect rule " has led equipped with x -ray plant, adequate surgical equip- AFRICAN REGION 105 ment and modern facilities.Tuberculosis cases are Public health activities are concentrated mainly on treated in special wards at district hospitals, and measures for the prevention of communicable disease special maternity wards are provided at the larger rather than on general hygiene and sanitation.The hospitals. A new health centre and 23 dispensaries health personnel is small and insufficient to deal with are located at strategic points throughout the country. all health problems. In six of these accommodation is provided for the In planning the future development of health ser- regular visits paid by the medical staff, who also vices, emphasis will be placed on the expansion of travel widely to outlying centres.In addition, mis- rural health services and the improvement of envi- sions are responsible for regular visits to 17 dispensa- ronmental hygiene by increasing the number of ries, bringing the total number of dispensaries and dispensary units or health centres throughout the clinics to 40.In 1955, a European district nurse was country.This will entail the training of sufficient sent to Ghanzi, some 200 miles from the nearest local personnel. medical officer and hospital. A small dispensary with Although there is no section specifically charged in- patient accommodation has been set up at this with health education, this work is carried out by centre, enabling the district nurse to hold maternal various agencies. and child welfare clinics in addition to other work. There is no medical school in the Protectorate, but Malaria is endemic in certain areas and difficult to the training of auxiliary personnel isundertaken. control owing to the seasonal migrations to agricul- Nurses are trained in four government and four mis- tural lands, making the population more susceptible sion hospitals; facilities for training in nursing and to infection.In most settlements malaria is now midwifery at two of the government hospitals are good. efficiently controlled by residual spraying. The training of African nurses consists of a three - A serious attempt is being made by the Government year course in general medical and surgical nursing to control tuberculosis, following a number of limited and a one -year course in midwifery, at the end of which surveys, which showed a high prevalence of pulmonary candidates receive a local certificate and are recognized tuberculosis.As a result, mission hospitals are pro- as staff nurses.The High Commission Territories vided with free antibiotics, and plans are being for- Nursing Council controls the training and registration mulated for the extension of hospital accommodation of all nursing staff.There are relatively few candidates for the treatment of tuberculosis. under training.Pupil dispensers and sanitary Diphtheria, whooping- cough, pneumonia, measles tors receive their training under the direction of medical and mumps are among the most prevalent diseases. officers, and health inspectors are required to pass Following serious epidemic outbreaks of diphtheria local examinations. and whooping- cough, a mass immunization campaign In the absence of a research organization or institute, was started, but it had to be abandoned owing to the some research work has been carried out with other difficulties resulting from local conditions; inoculations bodies, for example with the South African Institute are, however, being offered successfully at hospitals for Medical Research, on tuberculosis, extra -venereal and dispensaries. treponematoses, and nutrition.
BELGIAN CONGO
The Belgian Congo is in Central Africa and is composed Falls and rapids between Matadi and Leopoldville are avoided roughly of the southern and some of the northern part of the by a railway some 350 kilometres in length.The area of the Congo basin.It is bounded on the north by French Equatorial territory is 2 345 525 square kilometres. Africa and Sudan ; on the east by Uganda, Ruanda -Urundi, The total population in 1956 consisted of 12 843 574 indigenous Tanganyika Territory and Northern Rhodesia; on the south inhabitants, 97 371 white and 1433 Asian.The African races are by Northern Rhodesia and Angola, and on the west by French mainly of Bantu -Negro stock and the principal languages are Equatorial Africa and the Portuguese enclave of Cabinda. Swahili, Lingaa, Kikongo and Tshibula.There are several types There is a narrow coastal strip on the northern bank of the Congo of social and political organization; the tribes who live by hunting delta.The character of the country varies from the mountainous are still in the patriarchal stage; when the family group becomes regions of the east to the central depression drained by the Congo too large a section breaks off and forms another group.In and its tributaries.The eastern boundary coincides approxi- the agricultural tribes, migration is rarer and the sense of mately with the Great African Rift Valley.The Congo and its coming from a common stock is more deeply rooted: there is tributaries provide about 12 000 kilometres of navigable water- a complete hierarchy reaching outwards from the family to the ways.Leopoldville is the capital and Matadi is the chief port. group, the clan, the sub -tribe and the tribe.The chief at each 106 FIRST REPORT ON THE WORLD HEALTH SITUATION
level is generally the oldest person in the community ; he exercises preventive order, and enforcement of international and his authority with the assistance of notables and elders.Such internal public health regulations; societies are equalitarian and highly decentralized. The normal African diet is based principally on vegetables (4) medical laboratories responsible for routine and farinaceous plants.In the forest areas, manioc, beans and analyses, medical research, and the preparation of bananas are plentiful and form the staple foods.Sweet potatoes biological products for use in curative or preventive are grown up to an altitude of about 1800 metres.Rice, maize, millet, lentils, groundnuts and sugar -cane are also grown. medicine; At higher altitudes, beans and similar vegetables replace manioc (5) medical training schools. and banana, and are supplemented by millet and sorghum. Apart from the river tribes, who live largely on fish, the popula- In addition to government activities in medical and tion generally lacks proteins initsdiet -especially animal public health matters, assistance isalso given by proteins. philanthropic associations, large industrial concerns The main resources of the territory are the mining and export of metal ores and metals.Vegetable products, principally and religious missions. coffee, cotton and palm oil, are the chief secondary resources. Medical facilities in the Belgian Congo in 1956 Typical industrial products are cement, lime, bricks and textiles. included 293 hospitals, with 42 910 beds; 115 clinics The country is divided into six provinces, which are sub- (government, mission and private), with 1139 beds; divided into 19 districts and 122 territories.Each province has a governor who is assisted by a provincial advisory council. 1952 dispensaries and infirmaries, with a total of The ten -year development plan, instituted in 1950, is being 15 362 beds; and 179 specialized institutions for the carried out by the Administration with the assistance of semi - treatment of leprosy, tuberculosis and trypanosomiasis. governmental agencies such as the Colonial Transport Office, There were 5.6 beds for every 1000 inhabitants. the Electricity and Water Supply Board, the Native Welfare During 1956,2 413 735 Africans were treated in Fund, the National Institute for Agronomical Studies in the Belgian Congo and the Institute for Scientific Research in government hospitals alone, 445 633 of them as in- Central Africa. patients.The medical staff consisted of 643 physicians There is special inter -racial education, given in the French (or one per 20 000 population), 62 pharmacists, 37 den- language and on the same lines as in Belgium.There is also tists, 13 biologists, 581 medical auxiliaries and health generalized education, adapted to the needs and potentialities of the majority of the Congolese; primary instruction is given workers, 1084 female nurses, 1161 male nurses, medical in the vernacular, and more advanced instruction is given in assistants and orderlies, 283 midwives and midwifery French.Education is free, but not compulsory. aides and 3256 auxiliary male nurses. A Faculty of Medicine was added to the Lovanium Health Congo University Centre of Leopoldville in 1954. There is a central health department in Leopoldville, In 1955 special schools of tropical medicine were which is administered by a chief medical officer assisted established at Leopoldville, Stanleyville and Elisabeth - by a deputy chief medical officer, health inspectors and ville,for the express purpose of providing post- a chief pharmacist.The central health department graduate training for nurses and midwives with a is responsible for the organization and co- ordination Belgian diploma or recognized equivalent.African of health and pharmaceutical services, medical labo- medical assistants are trained in three special schools, ratories, health inspection services and medical train- the six -year curriculum including two years' practical ing. training in hospitals and laboratories.Other training In each province the provincial medical officer, facilities include 11 schools for male nurses; three assisted by a deputy, acts as director of medical ser- schoolsforsanitarians,four forstudent nurse - vices and adviser to the provincial governor.Each midwives, 33 for midwifery aides, and 70 schools with provincial medical department consists of: a one -year curriculum for the training of auxiliary (1) a division for the administrative co- ordination male nurses. and guidance of all sections or institutions engaged in Medical care in hospitals and dispensaries is free medical and public health work; of charge to all Africans in the lower income groups. Similar facilities, including accident insurance, are (2) a medical assistance section, responsible for the provided by commercial undertakings in accordance organization and management of medical establish- with the labour laws. Out of a total budget for 1956 ments (general hospitals,clinics, maternity homes, of1 102 509 000 Belgian francs (US $ 22 050 180), rural medico -surgical centres and dispensaries, special per capita expenditure on medical care was approxim- units for tuberculosis, mental disorders and leprosy), ately 86 Belgian francs (US $ 1.72). and of mobile medical units which undertake detection The main efforts of the health services are directed of the main endemic diseases in rural areas; towards the improvement of living conditions (housing, (3) a public health section in charge of environ- diet, general environmental sanitation, etc.); the detec- mental sanitation, insect control, examinations of a tion, constant surveillance and treatment of the main AFRICAN REGION 107 endemic diseases (malaria, trypanosomiasis, leprosy chemotherapy,aswellasbychemoprophylaxis and tuberculosis); maternal and child health and inareasof extremeendemicity.In1956only welfare; and the elimination of social evils such as 1604 cases were recorded out of 6 122 524 persons alcoholism and venereal diseases. examined. Although malaria isstill prevalent, most of the Systematic case -finding and treatment of leprosy larger centres are more or less free of it, owing to the have continued.In 1956, 275 293 leprosy cases were campaigns against insect vectors which have been treated -about two per cent. of the whole population. carried out for several years.Malaria is also disap- Non -contagious cases are treated in the rural dispen- pearing from some of the rural areas, where intensive saries and medical centres, and contagious cases are insect control measures are undertaken.In other segregated in organized communities under the direc- areas, chemoprophylaxis for infants and young child- tion of specialized personnel. ren, and partial insect eradication, are carried out. The prevalence of smallpox has been considerably Large -scale tuberculosis surveys have been con- reduced as a result of systematic vaccination and re- ducted in recent years in both urban and rural centres vaccination. by means of tuberculin- testing and mass radio- Maternal and child health activities have met with graphy, and more than one million people have been an increasing response.Special children's wards are examined.The number of cases of pulmonary tuber- now attached to the general hospitals in the main culosis is estimated at about 96 000 out of a population centres, and a Red Cross paediatric clinic has been of 12 million, with a tuberculosis morbidity rate of established in Leopoldville. A growing number of approximately eight per thousand.There are seven African women attend the maternity hospitals, where tuberculosis treatment centres with a total of 1275 beds, 189 393 deliveries were recorded in 1956 (more than which is clearly inadequate.In 1955, 61 105 persons 40 per cent. of all births in the Congo), as against were vaccinated with BCG. 161 775 in 1955.The MCH services include ante- Available statistics show that 189 892 persons were natal and post -natal clinics in general hospitals and treated for venereal diseases in 1956. dispensaries throughout the territory.Provision has The incidence of trypanosomiasis has been reduced been made for the training of African MCH personnel, tosomeextentbysystematiccase -findingand nurse -midwives and midwifery aides.
BRITISH SOMALILAND PROTECTORATE
The Somaliland Protectorate occupies the north -east horn yet been entirely surveyed and large areas of the potential of the African continent, along the south of the Gulf of Aden. mineralbeltremain unexplored. In1954,450 pounds It is bounded on the east by Somalia under Italian administra- (about 200 kg) of high -grade columbite and beryl were produced tion, on the south and south -west by Ethiopia and on the west during prospecting work. A Colonial Development and Welfare by French Somaliland.The territory has four main geogra- Scheme is investigating the possibility of a sound commercial phical features: (1) an almost bare, gently rising alluvial plain, fishing industry. ranging in breadth from about 800 metres in the east to about The normal community is the nomad tribe with its camels and 100 kilometres in the west; (2) a maritime plain, with a similar flocks, which makes it difficult to organize any system of com- slope, on which are many limestone ridges and hills of igneous munity development and welfare.Community centres are, rock; (3) a vertical escarpment of limestone about 600 metres however, established in all the main towns and these are provided thick; (4) from the top of the escarpment, a long, wide and almost with wireless sets, periodicals, posters and other facilities.The featureless plateau slopes gently downwards to the south -east community response is most evident in agriculture, particularly into the Haud, a belt of thorn wilderness and pasturages, which in regard to soil conservation schemes. extends into Ethiopia and to Somalia. The area of the country is 176 120 square kilometres.The Health population was estimated in 1956 at roughly 640 000, almost The Health Department, with headquartersat entirely of Somali race, and nomadic. Hargeisa, is directly administered by the Director of The countryisdivided for administrative purposes into six districts, each of which is in the charge of a District Comis- Medical Services, who is a member of the Executive sioner, assisted by the Aki! (Chief) who is paid by the Govern- and Legislative Councils and is adviser to the Govern- ment to explain and carry out policy and to maintain order. ment on medical affairs.In addition to the Director, The economy is based almost wholly on nomadic pastoralism: the expatriate seniorstaff consists of one senior most of the population is engaged in stock -raising, relatively medical officer (health), one senior medical officer few in agriculture and other pursuits.Trade is almost entirely confined to the export of a few primary products and the import (clinical), whoisMedicalSuperintendent,three of foodstuffs and manufactured goods.The territory has not special grade medical officers,six medical officers 108 FIRST REPORT ON THE WORLD HEALTH SITUATION
including one female medical officer, one dentist, Maternal and child health services are proving one matron,sixnursingsisters,one laboratory increasingly popular. A weekly ante -natal clinic is technician and one medical storekeeper.One chief held at the Group Hospital, Hargeisa, and clinics are medicalassistant,threesenior medical assistants also held at other centres.As in most Moslem and one hospital secretary - who are also senior countries,medicalworkamong women made staff - are Somalis.The junior medical staff are all slow progressatfirst,but women inHargeisa Somalis apart from six Indian clerks; they consist of are now reported to be attending hospital more seven medical assistants, one health superintendent and readily. 528 other workers.One Royal Army Medical Corps There are 12 rural dispensaries and three sub - officer is attached to the Somaliland Scouts.Apart dispensaries throughout the country, as well as three from a medical officer employed by an engineering firm, others inside the adjoining Ethiopian territory which there are no private practitioners and no missionary serve areas frequented by Protectorate tribesmen; societies or other agencies engaged in medical work. there is also an out -patient dispensary in Hargeisa. Expenditure on the Health Department for 1958 -59 Trainedtribalaidestreatsimple ailments when is estimated at £165 185 (US $462 518), representing necessary. 25.5 per cent. of the total unaided services expenditure The most common diseases in the territory are and 9.6 per cent. of the total budget.There are eight respiratory infections, tuberculosis and malaria.The hospitals (including a tuberculosis hospital and a control of mosquitos presents great difficulties in mental hospital) with a total of 861 beds, of which many areas; in particular, the problem of Anopheles 185 are allocated for tuberculosis patients. gambiae - the cause of seasonal epidemics in the The progress of technical training is still hampered Haud - has not yet been solved. A WHO team is by lack of general education.Courses are run for working in the country with the object of mapping the training of local personnel (male dressers, female out the distribution of endemic malaria, and, at the nurses and assistant health superintendents) at the same time, is following the course of epidemics with school attached to the Hargeisa Group Hospital, a view to preventing their occurrence.As a temporary where the teaching is given by departmental medical measure, centres of mosquito- breeding are sprayed officers and nursing sisters.Training of dressers is with residual insecticides, and the huts, frames and carried out as follows : in the case of low educational mats carried on camel back by the nomads are standard entries, there is an initial period of two sprayed as opportunity offers. years' practical instruction (Grade III), followed by With regard to tuberculosis, a survey carried out a further two years' dresser training (Grade II), or by WHO in 1956 showed a high positive rate in certain - in the case of probationer dressers who are boys age -groups, and, out of 1600 persons examined at holding Intermediate School Certificate - direct re- random in Berbera and Burao, about 20 per cent. cruitment for the Grade II Dressers' Course.After were found to have acid -fast bacilli present in a single qualifying, candidates from both these courses can specimen of sputum demonstrated by direct micro- proceed to the Grade I course, and finally to promotion scopy. A scheme for the control of tuberculosis as medical assistants by selection.The training of was evolved in the light of the information gained from female nurses is similar to that of dressers, but they this survey and from the Health Department records. suffer even more than the males from lack of education. This scheme is designed to :(a) tuberculin -test the In 1958, 13 Somalis, including two women, were younger age -groups and give BCG vaccination to receiving training in the United Kingdom, as shown negative reactors; (b) find cases; (c) treat patients in the following table : with PAS and INH, using hostel accommodation to provide the nomads with a domicile until sputum Field of study negative, and then follow up with out -patient treat- ment; (d) raise the standard of living and housing nurses health of the population by propaganda and health educa- Training institution doctors (State dentists inspectors Registered) tion.Thefirstbuildingoperationsunderthis scheme began inlate1957, and thefirstunits M F M F M F M F were opened in September 1958.Itis hoped to take approximately 800 -1000 new patients for treat- Medical schools . 2 ment eachyear,andtohave 1600 -2000 under treatment at any one time.Mass miniature x -ray Hospitals . . . -- 2 2 ---- Technical colleges 4 1 -- 1 - 1 - is not being used, at least until the organization is running smoothly. AFRICAN REGION 109
In research, a good deal of field work is being done atHargeisa and Berbera,and smalleronesat on malaria, tuberculosis, nutritional conditions and seven other townships but, generally speaking, the the epidemiology of tropical ulcer. watersupplyisinadequate.For stock -watering, The whole question of water supplies is a vital the nomads use the permanent shallow wells and one.All piped water suppliesare under govern- underground tanks available in many parts of the ment control.There are two fairly large systems country.
CAPE VERDE
The Portuguese Province of Cape Verde consists of ten islands 1956 the proportion was 4.7 per cent.These percen- and a number of islets, of volcanic origin, which lie in two groups tages refer exclusively to the amounts set aside for in the Atlantic Ocean: Barlavento (windward) and Sotavento (leeward). running the health services, since the costs of construc- The Barlavento group includes Sao Vicente, Santo Antao, tion and equipment of hospitals and other establish- Sao Nicolau, Santa Luzia, Sal and Boavista; the Sotavento ments are met from another fund. group includes Maio, São Tiago, Fogo and Brava.The Data obtained from the civil registers give a death archipelago çovers a total area of 4033 square kilometres; rate of 20.05 for 1954. it lies 455 kilometres off the coast of Africa, between latitudes 14° 48' and 17° 12' north and longitudes 22° 41' and 25° 22' west. Malaria is the principal endemic disease in the The population numbered 147 097 at the 1950 census. islands, and a control campaign is being carried out For administrative purposes the Province is divided into at the present time; surveys are under way to identify councils and boroughs, one for every island, and the supreme the vectors of the disease in the various islands in authority is vested in the Governor, whose seat is the city of Praia (Sao Tiago). order that an eradication programme may be under- taken.In the island of Sal, Culicidae (particularly Anopheles gambiae) have been eradicated, and it is Health proposed to undertake campaigns for the eradication The health services were reorganized on the basis of A. gambiae inSao Vicente,Sao Tiago and of a Decree of 1945 relating to the general structure Maio. of health services in the Portuguese overseas provinces. At the same time surveys will be made of the The 10 district health services and 17 health units epidemiology of filariasis and ankylostomiasis in the are under the technical and administrative direction island of Sao Tiago. An important development has of the Chief of the Central Health Department. been the eradication of Aëdes aegypti from the island District health services are in the charge of one of Sal and from Sao Vicente. or more medical officers, assisted by the necessary Three infant welfare clinics and two maternity nursing staff; the health units are run by one or centres give advice on infant feeding and treatment more male nurses, who work under the direct super - for the diseases of infancy; other dispensaries provide vision of the district medical officer. pre -natalservices, and care during child -birthis The indigenous population is provided with free afforded by the maternity centres. medical care through government hospitals, aid posts, The government health personnel impart health health units and dispensaries.At the end of 1956, education to the people to help them raise their there were the following health establishments in the standard of hygiene and defend themselves against Province: two central hospitals (at Praia and São the main endemic diseases of the area in which they Vicente), one regional hospital, six regional aid posts, live. 17 health units, three infant welfare centres, one lepro- In the city of Praia the public welfare authorities sarium, one psychiatric hospital, two laboratories for are building low- priced dwellings for people in the clinical analyses and one pharmaceutical laboratory. lower income groups.Practically all government of- The staff of these establishments consisted of 17 ficials in the islands live in houses provided by the physicians, 44 male nurses, one pharmacist and one Government.The cities of Praia and Sao Vicente midwife. have a potable water supply and a drainage system. In 1954, 6.9 per cent. of the total budget of the Pro- All recently constructed dwellings are equipped with vince was allocated to the health services, and in sanitary installations. 110 FIRST REPORT ON THE WORLD HEALTH SITUATION
COMORO ARCHIPELAGO
The Comoro Archipelago, consists of the islands of Mayotte, was 10 per cent., exclusive of grants received under Anjouan, Grande Comore and Mohéli.These islands lie in development plans. the northern entrance of the Mozambique Channel, between the east coast of Africa and the north point of Madagascar, about The health services provide free medical care and 500 kilometres from that point.The area of the whole territory preventive services for the entire indigenous popula- is about 2180 square kilometres, and that of the largest island, tion, whose response is demonstrated by the fact Grande Comore, is1148 square kilometres.The capital is that in 1956 a total of 2439 in- patients was recorded Dzaoudzi, on the island of Mayotte.The islands are of volcanic in hospitals and medical stations, and 316 621 out- origin and the soil is fertile. In December 1956 the total population was estimated at patient consultations were given.Furthermore, the about 177 000, of whom 1006 were non -indigenous. industrial medical services recorded another 50 000 The principal local foods are mountain rice (a luxury), green consultations during the same year. bananas cooked in water, bread made from maize or manioc Increasing emphasis has been placed on preventive mixed with ground coco -nut, yams and taro. Education is free.In 1955, there were 33 primary schools, measures in recent years, particularly in connexion with 2647 pupils, one secondary school, with 106 pupils, and with the control of the main endemic diseases in the three technical schools, with 92 students. territory. A malariaeradicationcampaignwas There are four administrative divisions, one for each of the started in the islands of Mayotte and Mohéli in 1954, four main islands. including the distribution of antimalarial drugs to children of school and pre -school age; in mid -1956 Health a similar campaign was started in the island of An- jouan.Altogether,during1956, 3 923 000 square The health services of the territory are directed by metres of walls were sprayed, and 25 307 children a Chief Medical Officer, whose headquarters are at received weekly chemoprophylactic treatment.The Dzaoudzi.He is also medical officer of health for average spleen index dropped from 72 per cent. the island of Mayotte, and is assisted by a superin- at the beginning of the campaign in 1954 to 12 per tendent of pharmaceutical stores and by adminis- cent. at the end of 1956. trative staff.There are two other medical districts, Filariasis (Wuchereria bancrofti) is a fairly serious each in the charge of a medical officer, one for problem in the islands of Mayotte and Mohéli. Grande Comore and one for the islands of Anjouan A survey carried out in 1955 -56 showed that of 1442 and Mohéli.There isalso an industrial medical persons examined in Mayotte, 37.1 per cent. were service, with a physician and a number of nursing positive; in Mohéli the number examined was 1996, stations. of whom 43.7 per cent. were positive.The examina- In 1956 there were three general hospitals in the tions were carried out between the hours of 8 p.m. territory; one on the island of Mayotte (60 beds), and 11p.th.Furthermore, out of 6636 persons one on Anjouan, opened in 1955 (60 beds), and one examined for elephantiasis in Mayotte, and 5736 on Grande Comore, also opened in 1955 (90 beds). persons similarly examined in Mohéli, the infestation They havemedical,surgical,obstetrical,dental, rate was found to be 1.7 per cent. in the first group radiological and laboratory services.There were also and 2.7 per cent.inthesecond.Wall- spraying three rural medical stations, with a total of 94 beds operations have not been found very effective against for in- patient accommodation, and 20 out -patient the Culicidae, and a larvicidal campaign was therefore dispensaries.There are seven pharmaceutical stores initiated in 1956. in the various islands. The number of cases of syphilis has remained The staff of the health services in 1956 comprised fairly constant for some years, representing about four physicians and one dentist with French or 8 per cent. of out -patient attendances.In 1956, equivalent degrees, and the following staff trained in 11 751 cases were recorded, of which 4476 were treated Madagascar and seconded from the Public Health as hospital in- patients.Yaws is endemic in the terri- Service of that territory: seven physicians, one health tory and has remained stationary for some time, visitor,five midwives, two malaria assistants, and since treatment given in medical stations has only 33 nurses (excluding auxiliaries). succeeded in reducing the infection within a com- The proportion of the territory's total budget de- paratively limited radius of the stations.The total voted to the maintenance of the health services in 1956 number of known cases was 8200 in 1954, 9000 in AFRICAN REGION 111
1955, and 9800 in 1956.Plans were drawn up for Type of service 1954 1955 1956 a large -scale yaws control campaign to begin in 1957. Children : Attendance at infant welfare clinics Three hundred and nine cases of leprosy were (0 -1 year) 3300 9600 7600 known and treated in1956.Each caseis being Attendance at child welfare clinics treated with sulfonamides at the nearest medical (1 -4 years) 9500 17900 21600 station and only the severe and disabled cases are kept as in- patients in hospital. Health education of the public is in its early stages Tuberculosis constitutes the main health problem, but is being initiated through the medical stations accounting for 30 per cent. of all hospital days re- and dispensaries, in schools, and among the various gistered by the health establishments of the territory; youth associations. 178 cases were treated in 1954, 97 in 1955 and 147 At the end of 1956, five students from the terri- in 1956. tory were studying at Tananarive Medical School Modern midwifery and obstetrical services have in Madagascar, and one student was at a medical been slowly accepted by the female population. faculty in France. The following table shows the slight increase in Problems of water supply vary in the different institutional deliveries between 1954 and 1956, and islands.Reservoirs and dams exist in some localities the much greater increase in attendance at infant on the islands of Mayotte, Anjouan and Mohéli, and child welfare clinics : and others are being built.On the island of Grande Comore, however, there are no permanent water- Type of service 1954 1955 1956 courses, and the volcanic nature of the ground pre - Mothers: culdes the drilling of wells; tank storage has been Attendance at pre -natal clinics 900 900 1 100 Institutional deliveries 450 530 690 found to be the only solution, and the programme Attendance at post -natal clinics 900 700 600 of construction of tanks is progressing each year.
'FRENCH EQUATORIAL AFRICA
French Equatorial Africa consists of four territories forming territorial administration; as such, he presides over the govern- the Federation of Gabon, Middle Congo, Chad and Ubangi - ment council for the consideration of certain matters.The Shari.It is bounded on the north by Libya, on the east by government council is composed of six to twelve members, Sudan, on the south -east by the Belgian Congo, and on the elected by the territorial assembly; each member bears the title west by French West Africa and Cameroons.It has an area of minister and is in charge of a ministerial department.The of roughly 2 723 000 square kilometres with a population, member who receives the most votes is given the title of President according to the December 1956 census, of 4 853 000 Africans of the government council, which is the instrument of the and 25 207 Europeans.The African population may be territory's executive powers and is responsible for the administra- divided into the Sudanese and the Bantu groups.There are tion of the territory's public services and for implementing the also some pygmies. assembly's decisions.The territorial assembly is made up, There are about half a dozen fairly large towns, but most of according to the territory, of a varying number of members the population live in villages, which are often widely scattered; elected by direct universal suffrage and by a single electoral body; there are some nomadic tribes in Chad.The general community it votes the budget, determines and votes the taxes, rates and system is tribal. duties to be levied; and draws up regulations applicable to the The High Commissioner of the Republic, whose seat is in territory on a large number of subjects. Brazzaville, is both the representative of the French Government The people derive the greater part of their livelihood from the and the head of the group of territories which make up French equatorial forests, from agriculture, and from cotton (which has Equatorial Africa.As representative of the Government, he is become the main resource of Chad and Ubangi- Shari).In in charge of the State public services, both civil and military. Chad there is also some stock -breeding.There has been a As head of the group of territories, he is responsible for ensuring steady increase in agricultural production since 1952, parti- that the decisions of the Grand Council are carried out.The cularly in timber and cotton, but coffee, cocoa and sisal have members of the Grand Council are elected by the territorial also gained in importance. A similar rise has been noted in assemblies (of which they are also members), each territory industrial production, for example in the output of groundnut sending five representatives.The Grand Council is responsible and palm oil, soap, beverages, lead ore, diamonds, columbite for administering matters of common concern to all the territories and tantalite.The principal imports are cotton fabrics, ma- in the group; for voting the over -all budget; and for drawing up chinery, motor vehicles, motor spirit, wine, beer, and sugar. regulations on certain questions applicable to the group of The principal exports are cotton, timber, coffee, cocoa, cattle, territories as a whole. diamonds and gold. The Governor of each territory is, on the one hand, the rep- Two four -year plans for the economic and social development resentative of the Government of the Republic and of the High of the territory have been carried out; the first commenced Commissioner of the Republic, and, on the other, chief of the in 1947 and the second in 1953. 112 FIRST REPORT ON THE WORLD HEALTH SITUATION
The essential aims of the educational policy are to raise the medical centres in the principal towns of the larger general level of living and to train the best elements as leaders districts, there are medical posts and dispensaries in in the community; to give boys and girls a parallel education in order not to upset the balance of the African family; and to the villages, and consultation centres in markets and make compulsory schooling and mass education possible by similar gathering places.In 1956 there were 355 such training African school- teachers.In French Equatorial Africa centres.There were also 30 mobile units which as a whole, the proportion of children attending both public and travel all over the country through the bush, with private schools rose from 2.5 per cent. in 1945 to 19.5 per cent. in 1954. theobject of detecting and controlling endemic Since 1953, rural development has been planned on a wider diseases, giving vaccinations against yellow fever and basis than before, with the object of maintaining and improving smallpox, and general care for the sick.A new soil fertility, raising the income and levels of living of the general hospital with modern equipment and 650 beds farmers and, in particular, of regrouping villages and improving was to be opened in Brazzaville early in 1958, and a housing. Manioc is the basic food but does not provide a balanced diet. number of other modern hospitals and medical Efforts have been made to improve nutrition by developing other centres are under construction in various towns, food crops and by the conservation and improvement of while existing hospitals and clinics are being renovated. livestock. In 1954, the staff of the public health services consisted of 180 medical officers, three dentists, 1657 Health male and female nurses, 45 midwives 84 technical workers and 15 pharmacists. A further 21 medical A law of 23 June 1956 placed the public health officers, seven dentists, three midwives and 24 phar- services under the responsibility of the territorial macists were in private practice.About 14 per cent. governments, and under the direct authority of the of the total budget is devoted to public health services. Minister of Public Health or Social Affairs of each In 1956, about 70 per cent. of the African popula- of these territories.The Minister is assisted by a tion were examined by some unit of the health services, Director (or, in some territories, an Inspector) of and each patient was examined on an average three Health Services, and ensures the provision of medical times during the year; 2 per cent. were admitted to care services through health establishments -hospitals hospital, with an average of 23 hospital days per and treatment centres of various types -and by means in- patient. A decrease in the number of hospital of mobile units.The latter, which are called the days has been noted, owing to the development of Territorial Mobile Health and Preventive Services out -patient care for leprosy and trypanosomiasis, since (Services territoriaux d'Hygiène mobile et de Pro - these diseases formely entailed prolonged periods of phylaxie- S.T.H.M.P.), undertake mass campaigns in- patient hospital care. and control of important endemic diseases such as Considerable progress has been made since 1954 in leprosy,malaria, trypanosomiasis and treponema- mass campaigns for the control of the main endemic toses. diseases.In January 1954, for example, only 56 670 In Brazzaville, the control of important endemic cases of leprosy had been officially recorded, whereas diseases is directed by a Permanent Inspector of Health at the end of 1956 the number registered had reached and PreventiveServices, who isresponsiblefor 136 150, of whom 126 006 were being treated.Despite studying the diseases most frequently observed in the the lengthy treatment involved, 6021 cases are no group of territories, and their treatment; for research longer contagious, and 21 have been definitely cured. on and co- ordination of preventive measures to keep Yaws exists mainly in Gabon, Middle Congo and them in check; and fo r supervising the application of southern Ubangi- Shari -all hot and humid forest thesecurativeandpreventivemeasures.Heis regions.Since 1955 penicillin has been used for both assisted by chiefs of the following technical sections: active cases and contacts.As a result of mass treat- leprosy, trypanosomia sis,malaria, treponematoses, ment, the number of cases of yaws has decreased and nutrition. appreciably in comparison with previous years; in In 1954, government and private health establish- 1956, of the total number of patients treated for all ments included one general hospital (584 beds), diseases, 2.8 per cent. were suffering from yaws, as 13 secondary hospitals (20 88 beds), 179 medical centres against 6.9 per cent. in 1947. (4268 beds), 281 medical posts (5554 beds), and Malaria is still a serious problem throughout the 245 dispensaries. In addit ion, there were 136 matern- territory, but is being successfully controlled.Weekly ity clinics (938 beds), one tuberculosis centre, 33 doses of nivaquin have been administered to 70 387 leprosaria (2390 beds), on e psychiatry unit (24 beds), schoolchildren and to 33 256 children of pre -school and 27trypanosomiasisclinics(1126beds).In age.In 1956, 26 million square metres of walls addition to the main medical centre and secondary (14 447 dwellings) were sprayed with DDT. AFRICAN REGION 113
In 1956, 2759 cases of tuberculosis were treated, Trypanosomiasisisdecreasing;784 cases were more than three -quarters of them being of the pul- found in 1956 out of a total of 2 258 282 persons monary type.It has been found that tubercular examined. infections are fairly widespread, although the number Control of yellow fever continues, and since 1945 of active cases reported is comparatively small.A only six cases have been reported.In 1956, 1 578 633 campaign to assess the prevalence of tuberculosis by persons were inoculated with either yellow fever tuberculin -testing and x -ray examinations has begun vaccine or combined smallpox -yellow fever vaccine. in Brazzaville. There are a number of maternal and child health Venereal diseases constitute one of the main health centres in the larger towns.In 1956 they recorded problems; 79 820 cases of syphilis were treated in 258 000 ante -natal and 142 000 post -natal visits and 1956 as well as a large number of other diseases of 786 000 infant consultations. the same group. School medical inspection is carried out as a matter In all, 17 663 cases of amoebiasis were reported of routine;in1956,120 000 schoolchildren were in 1956, as against 14 411 in 1955.There were few examined out of a total school population of 150 000. hepatic complications and only a small number of Health education of the public is being extended deaths, but the disease is nevertheless one of the progressively to the whole population by means of major health problems of the territory.There are radio talks, advice by the mobile units in the bush, comparatively few reported cases of bacillary dysen- free distribution of layettes, posters on nutrition, tery, but intestinal parasites are very frequent.Of and booklets on infant care, food hygiene and diet 140 000 persons examined in 1956, 40 000 were found (including the use of local food in preparing meals). to be suffering from ankylostomiasis.Bilharziasis is Occupational health services have been organized, found mainly in Ubangi -Shari and Chad.Filariasis and the larger industrial and business concerns now occurs chiefly in the same areas; in the Mayo -Kebbi have their own medical officers. district it reached such proportions that a control A school for male nurses has been opened in campaign was undertaken in 1955 and 1956. Brazzaville, leading to the State Nursing Diploma A trachoma control campaign was started in 1956, (Diplôme d'Etat d'Infirmier), the only one recognized and experiments with self -treatment of conjuncti- in France.The first 13 students were admitted in vitis and trachoma, using aureomycin ointment, are 1956.There are also a number of local schools being made in the Fort -Lamy region. throughout the territory for the training of nurses.
FRENCH WEST AFRICA
French West Africa consists of eight territories: Senegal, of a larger community -the clan -the several families of which Sudan, Niger, Guinea,' Upper Volta, Ivory Coast, Dahomey, give one another mutual support.Families rarely live in isola- Mauritania.It extends from the Algerian and Libyan Sahara tion; they are nearly always grouped into villages under their in the north to the Gulf of Guinea in the south and to the chiefs; the normal community system in the rural areas is tribal. Atlantic Ocean in the west; on the eastitadjoins French The people of the forests are more individualistic than the others. Equatorial Africa.It has common frontiers with Ghana and The urban communities vary in size from large towns such as the British territories of Gambia, Sierra Leone, and Nigeria, with St Louis and Dakar, with over 60 000 inhabitants, to scattered Portuguese Rio de Oro and Portuguese Guinea and with the villages, and even groups of nomads in the north. Republic of Liberia.The total area is 4 633 985 square kilo- In rural areas the most usual dwellings are tents of wool, metres. cotton, or sometimes skins among the Moors and some of the The estimated indigenous population in 1956 was 18 258 900; Tuaregs; round huts of straw, clay or wattle and daub with a the estimated European and assimilated population was 83 000. conical thatched roof in Senegal and western Sudan; huts Three main groups may be distinguished in the indigenous covered with an ovoid roof and made up of two round huts population: (a) the Saharans, Moors and Tuaregs, who are joined in the middle, among the Senufo; rectangular houses of pastoral nomads ; (b) the Peulhs or Foulah, who may be nomadic, dry stone or brick with flat or slightly raised roof in some of semi -nomadic or settled; and (c) the Negro -African groups, the hilly parts of Sudan; in the forest, rectangular huts of rammed which comprise a large variety of races, speaking over 120 earth, straw or bark, with a double -sloped thatched roof.In languages and 600 dialects. most places the various huts of the same family are enclosed in The fundamental unit of African society is the enlarged a compound surrounded by clay walls or reed palisades. " family " group including several generations and usually under The usual African diet is mainly vegetarian.According to the authority of the eldest member. The group is usually part local resources, it is composed of a porridge of millet or rice, groundnuts, maize, manioc, yam, potatoes or bananas, generally 1 Since the end of the period under review, Guinea has become cooked in oil or butternut fat and seasoned with tomato an independent country. pimento etc.When obtainable, meat is included in the diet 114 FIRST REPORT ON THE WORLD HEALTH SITUATION
especially beef or mutton; much use is also made of fish, and by means of mobile units.The latter, which especially dried fish; in the pastoral regions milk and butter are important ingredients. are known as the Territorial Mobile Health and The High Commissioner of the Republic, whose seat is in Preventive Services (Services territoriaux d'Hygiène Dakar, is both the representative of the French Government Mobile et de Prophylaxie- S.T.H.M.P.), undertake and the head of the group of territories which make up French mass campaigns and control of important endemic West Africa.As representative of the Government, he is in diseases such as leprosy, trypanosomiasis, trepone- charge of the State public services, both civil and military.As head of the group of territories, he is responsible for ensuring matoses and malaria. that the decisions of the Grand Council are carried out.The An Adviser on Endemic Diseases is stationed in members of the Grand Council are elected by the territorial Dakar; under the authority of the High Commissioner assemblies (of which they are also members), each territory he is responsible for the co- ordination of and technical sending five representatives.The Grand Council is responsible for administering matters of common concern to all the territories assistance to the mobile units (S.T.H.M.P.), and also in the group; for voting the over -all budget; and for drawing up acts as consultant epidemiologist.He has at his regulations on certain questions applicable to the group of disposal, in carrying out these functions, units for territories as a whole. research and for training of personnel, and is assisted The Governor of each territory is, on the one hand, the repre- by the chiefs of the following technical sections : sentative of the Government of the Republic and of the High Commissioner of the Republic, and, on the other, chief of the trypanosomiasis, malaria,leprosy,treponematoses, territorial administration; as such, he presides over the govern- nutrition and eye diseases. ment council for the consideration of certain matters.The The medical services are reinforced by a number of government council is composed of six to twelve members, scientific institutions such as the Tropical Ophthal- elected by the territorial assembly; each member bears the title mology Institute of French West Africa, the Federal of minister, and is in charge of a ministerial department.The member who receives the most votes is given the title of Pre- Blood Transfusion Centre, the Pasteur Institute and sident of the government council, which is the instrument of the the African Diet and Nutrition Research Organiza- territory's executive powers and is responsible for the administra- tion, all of them at Dakar. tion of the territory's public services and for implementing The permanent health services of French West the assembly's decisions.The territorial assembly is made up, according to the territory, of a varying number of members Africa in 1956 consisted of five large hospitals (3500 elected by direct universal suffrage and by a single electoral beds), eight secondary hospitals (1960 beds), 1057 body; itvotes the budget, determines and votes the taxes, medical centres (13 274 beds), 204 medical posts rates and duties to be levied; and draws up regulations appli- (2746 beds), 870 dispensaries, 246 maternity homes cable to the territory on a large number of subjects. Industrial development is limited and the economy is almost (4466 beds) and 82 private establishments (600 beds). wholly dependent on three very sensitive agricultural markets In 1956 there were 575 physicians (267 with French -groudnuts, coffee and cocoa.These three products account State Diploma, 308 with local diploma), 39 pharmacists for about three- quarters of the total value of exports.Of the (26 State, 13 local diploma), 18 dentists, 462 midwives total area of about 470 million hectares, only 10 million can be (70State, 392 local diploma), 3942 male nurses used for agriculture.There are about 150 million hectares of pasture -land, of which 55 million are permanent and the rest (90 State, 3852 local diploma), 718 female nurses seasonal.The principal minerals mined at present are gold, (147 State, 571 local diploma), 180 technicians and diamonds, phosphates and iron.There are substantial forestry other staff. resources.The chief imports are cotton cloth, rice and other Medical education is afforded by the Dakar Medical foodstuffs, motor trucks, cars and spare parts, petroleum pro- ducts and machinery. School.This School is affiliated to the Institute of Education is free in all public schools.Students in secondary Higher Education of Dakar (founded in 1951) and and higher schools receive scholarships.Primary education is covers the first three years of the medical curriculum, compulsory so far as accommodation permits.Private schools after which students complete their studies in France. are subsidized by the territorial authorities; most of them are Training for pharmacists, nurses and midwives is run by missions. provided in institutions comparable with those in France.Auxiliary nurses and midwives are trained Health in Dakar and in some of the territories.The number A law of 23 June 1956 placed the public health of medical students in 1956 was 89, of whom 75 services under the responsibility of the territorial were African and 14 were European.More than governments, and under the direct authority of the 250 African students were studying at different medical Minister of Public Health or Social Affairs of each faculties in France. of theseterritories.The Ministerisassisted by Registration of civil status is compulsory only in a Director (or, in some territories, an Inspector) a few large towns, and vital statistical data are there- of Health Services, and ensures the provision of fore incomplete.However, the estimated birth rate medical care services through health establishments is between 40 and 50, and the death rate is between -hospitals and treatment centres of various types- 20 and 30. AFRICAN REGION 115
Progress during 1956 includes the modernization Systematic vaccination campaigns are being carried of the chief hospitals of the Federation, whose fittings out; in 1956, combined vaccination against smallpox and equipment are now considered comparable with and yellow fever was given to 3 632 338 persons; those of European establishments; the expansion of a further 1 829 564 persons were vaccinated against many aspects of health work; the increasinguse made smallpox alone, and 43 038 against yellow fever alone. by the population of the various health establishments Inoculationsagainstdiphtheria,tetanus,cholera, and mobile health units, which is indicative of in- plague and rickettsioses were also carried out, on a creasing confidence in these services; and the growing more limited scale. number of Africans who are eager to join the medical Although the endemic diseases mentioned above and para- medical staff. are gradually being brought under control through the The volume of work of the Mobile Health Services effective measures taken by the health services, tuber- isincreasing in various directions.Outbreaks of culosis is steadily becoming a more serious problem. smallpox and cerebrospinal meningitis occurred in Until it is possible to establish a network of effective 1956, and were rapidly controlled.Among 5 686 383 tuberculosis controlservices, BCG vaccinationis people examined 5334 new cases of trypanosomiasis being intensified and extended.The Pasteur Institute were found and 22 135 old cases were re- examined. in Dakar produced 707 220 doses of dry vaccine in Furthermore, among 5 547 315 persons examined, 1956 and 1957 for use in the territories. A systematic 44 415 new cases of leprosy were found; the total scheme for tuberculosis control has been started at number of leprosy patients in 1956 was 270 541, of the tuberculosis centre in Dakar. whom 4107 were treated as in- patients, 139 140 received Malnutrition is prevalent in certain parts of the ambulatory treatment and 1824 were treated by Federation, and isresponsible for mild forms of mobile units. A malaria control programme has been kwashiorkor; studies are being made of the nutritional in progress since 1952, and DDT and dieldrin have status of the people with a view to improving it. been used in three areas to control Anopheles gambiae Town water supplies are in some cases satisfactory and A. funestus.Although the spleen and blood and in others of doubtful quality.The immense parasite rates have decreased, transmission of the problem of water supplies for the rural areas is being disease has never been interrupted, owing to various tackled systematically.Excreta -disposal methods are factors.In the malaria control campaign the use of comparatively primitive even in urban areas, but insecticidesis now being combined with that of progress in this direction is being made.Measures schizonticides and gametocides.Considerable atten- are also being taken in the towns to provide adequate tion is also being given to the control of venereal low -cost housing for Africans of limited financial diseases, yaws, trachoma and bilharziasis. means.
GAMBIA (COLONY AND PROTECTORATE)
Gambia is on the west coast of Africa, near the mouth of the are also grown.There is a certain amount of seasonal immigra- river Gambia.It extends up both banks of the river for some tion from neighbouring territories by farmers who provide labour distance and is surrounded on land by French Senegal.The in return for a share of the crops.All the land, except in the total area of the territory is 10 300 square kilometres, of which Colony, is held in trust for the African population, and is the Colony of Gambia occupies 76 square kilometres and the allocated to the farmers by the Native Authorities.An experi- Protectorate the remainder.The rainy season lasts from June ment in mechanized rice -farming is being carried out by the to October and the annual rainfall varies between 75 and 150 cen- Government intheProtectorate.Livestockbreeding and timetres; for the rest of the year the climate is pleasant and forestry resources are also being developed; 33 600 hectares of generally healthy. gazetted forest areas are being brought under the charge of the The Colony of Gambia consists of Bathurst -the capital and Native Authorities, who are to undertake forest management. seat of the Governor -which is situated on the Island of St Mary The chief imports in 1954 were cotton piece- goods, motor at the mouth of the river, and the adjoining division of Kombo vehicles, kola nuts and sugar.The chief exports were ground- St Mary.At the 1951 census the population was 27 297, of nuts and palm kernels. whom about 550 were non -African; at that time Bathurst had Primary education is available for all children in the Colony 19 602 inhabitants, and in 1956 an estimated 21 022.The at a fee of ten shillings (US $ 1.40) a year, which may be waived Protectorate is the strip of land -about 11 kilometres wide in most in case of poverty.In the Protectorate, schools are managed places -on each side of the river above the Colony.Its popu- jointly by the Education Department and local schools' com- lation in 1955 was 246 000.It is divided into four Divisions, mittees, and there is an advisory board with an African majority. each under a District Commissioner. Teaching is mostly in English, but the vernacular is used in some The territory is predominantly agricultural, the principal crop of the Protectorate schools and Arabic in many Koranic schools. being groundnuts; millet and sorghum, rice and oil -palm kenels The school system comprises pre -primary, primary and secon- 116 FIRST REPORT ON THE WORLD HEALTH SITUATION dary education.In 1954, government schools in the territory previously.Elsewhere in the territory registration consisted of 38 primary schools (with 4078 pupils), one secondary of both births and deaths, and notification of births, school (96 pupils), three vocational training schools (42 students), and one teacher -training college (41 students); 92 students were are voluntary and very incomplete. pursuing higher education overseas. Of the quarantinable diseases,smallpox causes Outside the towns most of the African population live as some concern.In 1954 there were 107 cases with small farmers.The normal dwelling is the African grass- roofed one death; in 1955, 31 cases and three deaths; and hut.There is a certain amount of overcrowding in Bathurst, and 160 hectares of land have recently been reclaimed on the in 1956, 15 cases with no deaths.Vaccination is outskirts of the town for housing schemes within the means of undertaken by the health services, and, in 1956, lower income groups. 36 948 smallpox vaccinations were carried out. A survey of immunity to yellow fever was made in 1955, revealing a high prevalence of immunity in the greater Health part of the Protectorate, but a very low degree in the The medical and health services of Gambia are coastal area, which was therefore considered to be administered by a Director of Medical Services, at risk; a mass immunization campaign was under- assisted by a Medical Officer of Health responsible taken in1956, during which 18 934 persons were for preventive health services, and (since 1956) by vaccinated - an estimated 99.7 per cent. of the popula- a Senior Medical Officer for the Protectorate.Other tion at risk.In a series of mouse -protection tests medical and health staff include the following: Medical carried out before the campaign, immunity was Service: eight medical officers, two dental surgeons demonstrated in only 29 per cent. of the population, one dental technician, seven nursing sisters (including whereas after the campaign it was shown in 90 per matron), 107 junior male nursing staff,79 junior cent.No clinical cases of yellow fever occurred female nursing staff, two junior dental staff, and six in 1954 or 1955. technicians.Health Service: three health superinten- Malaria is endemic in the territory, and although dents, 33 health inspectors, seven community nurses complete mortality and morbidity statistics are not and attendants, and three sanatorium attendants. available, itis undoubtedly an important cause of The percentages of the territory's total expenditure disease and death.Accurate mortality dataare allocated to medical and health services during the available only for Bathurst, where they show a very period under review were: 1954, 9.4; 1955, 9.3; and high proportion of deaths among children under 1956, 8.0. five (three -quarters of all deaths from malaria during There are two general hospitals in the territory the period 1952 -56); expressed as a percentage of - the Victoria Hospital in Bathurst (with 155 beds deaths from all causes, malaria mortality for all in 1956) and one at Bansang in the Protectorate age -groups in 1956 was 13.58.Morbidity statistics (65 beds).The Victoria Hospital was completed for the territory as a whole are incomplete, but and brought into use during the period under review, returns from hospital out -patient departments in 1955 and includes, apart from general services, departments included 5829 cases of malaria - the commonest for infectious diseases, physiotherapy and dentistry. cause of out -patient attendance - and in 1956 rural Minor medical units attached to this hospital include health units, dispensaries and sub -dispensaries re- a mental hospital (24 beds), a home for the infirm corded9972cases - thesecond most common (20 beds, including two reserved for infectious cases), diagnosis.Routine control measuresarecarried and a sanatorium (23 beds).In rural areas there are out, and a great deal of research on the subject is in seven rural health units, 13 dispensaries and 24 sub - progress in the territory.Following a survey under- dispensaries. taken by a WHO consultant, plans were being made Vitalstatisticsare available only for Bathurst, in 1957 to intensify the malaria control programme. where the following rates obtained during the period Tuberculosis is a serious problem, especially in under review: Bathurst with its comparatively heavy concentration of population.The tuberculosis unit attached to the 1954 1955 1956 Victoria Hospital has 15 beds for males and eight Birth rate 33.3 37.4 42.5 Death rate 17.1 17.0 20.4 for females (the female ward was added in 1955), Infant mortality rate . . . . 115.1 94.8 111.8 and an out -patient tuberculosis clinic was opened at the Hospital in 1956.Cases notified in 1954, 1955 and The increase in the birth rate is considered to be 1956 numbered 49, 32 and 72 respectively, with a apparent rather than real, since, from 1956, the figures death rate per thousand of 1.4 in 1954 and 1.8 in 1955. have been based on notifications from the professional These increases are thought to be due to improved attendants instead of on registration by parents, as case -finding and more complete notification rather AFRICAN REGION 117
than to any significant increase in the prevalence of Maternal and child health services are provided the disease itself, as well as to a growing willingness in Bathurst at a special centre, and elsewhere at on the part of patients to undergo treatment in view 20 rural health units and dispensaries.Shortage of of thesatisfactoryresultsobtained with modern staff has been a serious handicap to the development drugs.Plans were made during the period for a of these services, especially in view of their popularity, tuberculosis survey of the territory (with assistance of which evidence is given in the following table:
from WHO), to be followed by a control programme. Type of service 1954 1955 1956 The prospective expansion of the town of Bathurst, Ante -natal clinics: which will result in better housing conditions, is also New cases 3634 3903 4346 Total attendances 16061 14349 16310 expected to help in checking the spread of tuberculosis. Venereal diseasesaretreatedinhospitals and Child welfare clinics : dispensaries.In 1956, 922 cases of syphilis (of whom New cases 7183 9433 9458 16 were treated as in- patients in hospital) and 4409 Total attendances . 63345 66462 69093 cases of gonorrhoea (29 of them in- patients) were Domiciliary midwifery: * Total births attended . 1114 1278 1335 recorded.These figures are probably not representa- tive of the territory as a whole, since the vast majority Service based on above clinics of cases are treated in rural dispensaries on the basis of clinical diagnosis by junior staff, but the over -all A clinic for schoolchildren is held in Bathurst; in prevalence of these diseases is unknown. A survey addition to the usual functions of a school clinic, it of treponemal diseases was made in the Protectorate also undertakes the treatment of minor ailments; in 1954, which revealed yaws and a condition believed in 1956 it recorded an attendance of 15 376, of which to be bejel in one tribal group; evidence pointed, 8403 were new cases. A survey of ascariasis in school- however, to a decrease in these infections, as late children was carried out in the Bathurst area in 1955 inactive signs of the disease were frequently discovered and 1956; of 1038 children examined, infestation was in adults, whereas very few new infectious cases were found in 37 per cent.The prevalence varied from found. school to school but was heaviest among children from A survey of leprosy was carried out in the Protect- poorer homes.Treatment by means of a single oral orate in 1954, revealing an over -all prevalence of 2.4 dose of piperazine citrate gave 87 per cent. clearance per cent. among the people examined. A leprosy in 237 cases.A dental survey carried out among control programme has been organized, in the charge schoolchildren in 1956 revealed that the permanent of a medical officer appointed in 1956, and equipment teeth of 858 (18.8 per cent.) of the 4552 children and drugs have been received from UNICEF. There examined required treatment. is a leprosy settlement at Alatento, in the Protectorate, Health education is carried out through talks by which had 29 patients in 1956. health inspectors to groups of people in their areas Research has been in progress for some time on the on simple health topics, and isalso disseminated snailvectors of bilharziasis,and fivevectors of through Commissioners and localauthorities, by Schistosoma haematobium were identified,aswell attendance at conferences of chiefs, where a " question as a vector of S. mansoni, of which a small focus and answer " technique is adopted, by official speeches, of infection was found in 1956 - the first report of and by means of the Government newspaper.Short- intestinal bilharziasis in Gambia.Observations were age of staff prevents the use of more systematic made on the mode of transmission, and experiments methods. in vector control were carried out with molluscicides. The diet of the population of Gambia is based Cases of bilharziasis treated in hospitals and dispen- primarily on bulrush millet, guinea corn and rice, saries numbered 752 in 1954, 420 in 1955, and 479 and secondarily on fish and groundnuts.The fairly in 1956.Since the disease occurs in a mild form in recent introduction of rice has improved the diet, Gambia, it is probable that the majority of sufferers but there appears to be a shortage of animal protein do not seek medical treatment and that these figures and of vitamin A, and it is not yet possible to gauge therefore represent only a small fraction of the cases whether the change from the local crops to rice may which actually occurred. give rise to a deficiency of vitamins of the B complex. Trypanosomiasis also occurs in a relatively mild A long -range school feeding and nutrition project form in Gambia, and its true incidence is not known. was started in Bathurst in 1956 with assistance from Hospital and dispensary returns during the period UNICEF and WHO, the beneficiaries being children gave the number of cases as 1149 in 1954, 1026 in under the age of six, pregnant and nursing mothers, 1955, and 995 in 1956. and schoolchildren between six and ten years. 118 FIRST REPORT ON THE WORLD HEALTH SITUATION
In- service training of dresser -dispensers and mid- Elsewhere in the territory the water supply usually wives to staff the rural health units and dispensaries comes from wells. is carried out at the Bathurst hospital, and plans are A new drainage system is being installed in Bathurst; being made for the organization of a nursing training the town is very low -lying and almost surrounded programme in the territory.At present, however, by water and it is therefore most important that it all staff have to be sent outside the territory for should be drained by properly levelled drains to training, and in 1956 two nurse -midwives and two prevent flooding during the rainy season and stop health inspectors were receiving training in the United mosquito- breeding.Bathurst also has facilities for Kingdom.The lowering of the previous educational the collection of night -soil, from which compost is standard for entrance to the examination for the Health manufactured (1214 tons in 1956).In the Protect- Inspector's Certificate of the Royal Institute of Health orate there is a limited system of night -soil collection, (West Africa) has recently made it possible for the trenches and Otway pits being used for its disposal.In first time for health inspectors from Gambia to enter larger villages refuse is disposed of by controlled for the examination; one certificate was obtained in tipping or incineration; elsewhere, refuse is buried in 1955, and another in 1956. swamps. Research on a wide range of subjects, with the chief In 1957, a five -year plan for development of the emphasis on malaria, is carried out by the Medical medicalserviceswas submitted for Government ResearchCouncilLaboratoriesatFajara,near approval;thisplanincludesimprovements and Bathurst, and at the Field Station at Kenaba. extensions to hospital buildings, installation of new Bathurst has a piped water supply, which is being equipment, fellowships for training health personnel, improved (with the help of Development and Welfare the construction of new health centres, dispensaries Funds) by the addition of water containing fluorides. and sub -dispensaries, and additional mobile facilities.
GHANA
Ghana became a sovereign State in 1957; the country embraces Health what was formerly the Gold Coast (Colony, Ashanti and the Northern Territories) and Togoland under United Kingdom The Ministry of Health is responsible for advice on Trusteeship.It lies on the Gulf of Guinea on the west coast the formulation of government policy and its execu- of Africa, between 5° and 11° north and between 3° west and 1° east, and covers an area of approximately 292 367 square tion in the field of public health, the administration kilometres. of health services maintained by the central govern- The 1948 census recorded an African population of 4 111 680, ment, supervision and guidance of health services the total population of all races being 4 118 450.The population maintained by local government authorities and was estimated to have risen to 4 536 000 at mid -1954 and to bodies receiving financial assistance from the central 4 691 000 in 1956. The chief natural resources of the country are gold, industrial Government, and the promotion of improved health diamonds, manganese, bauxite, forest products and cocoa, all of standards throughout the country. which are exported.Imports are mainly of consumer goods At headquarters (in Accra), the Minister of Health and machinery. is advised on technical and professional matters by In 1956, about 340 000 boys and 180 000 girls were attending 3499 primary, 1029 intermediate and 61 secondary schools. the Chief Medical Officer, and on administrative ques- There were also four government trade schools, four government tions by the Permanent Secretary.At the head- technical institutes, and 30 teacher -training colleges.Higher quarters of each region provision is made for a education is provided at the University College of the Gold Principal Medical Officer or a Senior Medical Officer Coast and the Kumasi College of Technology; in 1956 the former with appropriate staff responsible to headquarters for had 310 students (290 men and 20 women) and the latter had 593 students. the health services in the region. The total length of railways open to traffic in mid -1956 was The expenditure on health has gradually increased; 987 kilometres.There were 12 880 kilometres of trunk and in 1956 it was £3 000 200 (US $8 401 568) out of a secondary motor roads, of which approximately 2190 kilometres total revenue of £47 408 890 (US $132 760 823). This were bitumen surfaced, as well as 8000 kilometres of local roads. There are four airports, that in Accra having international represents 6.3 per cent. of the general revenue for the connexions. year, compared with 4.2 per cent. in 1953. AFRICAN REGION 119
Registration of births and deaths is not carried out In 1954 the principal causes of mortality, in order universally in the country, but there are 36 registra- of importance, were :malaria, diseases of the genito- tion areas (covering about 12 per cent. of the total urinary system, complications of pregnancy, child- population) under government auspices and pro- birth and the puerperium, pulmonary tuberculosis, vision is being made in a new Public Health Bill for broncho -pneumonia andtetanus. Theprincipal the compulsory notification of births and deaths causes of morbidity were :malaria, chronic ulcers, throughout the country.Figures available from the pulmonary tuberculosis, complications of pregnancy, 36 registration areas are as follows: child -birth and the puerperium, intestinal obstruction 1954 1955 1956 and hernia, and injuries from road accidents. Birth rate 37.4 42.0 46.3 In 1954, 6957 in- patients and 58 061 out -patients Death rate 21.1 32.8 21.3 Infant mortality rate 119.0 109.0 98.0 were treated at government hospitals for malaria, which, as shown in the preceding paragraph, is the There were 73 hospitals in the country in 1956; most important cause of mortality and morbidity. 39 were government -owned or conducted by missions Research is being undertaken into malaria control fortheGovernment,threewere mission -owned, and the malaria service is being developed. 11 were owned by mining and timber companies and Tuberculosis in its pulmonary form is common, 12 were mainly in private hands.The government and surveys have been undertaken to assess the extent hospitals are of two main types -the central hospital of the problem and the best methods of control of (four in number, at Accra, Kumasi, Sekondi and the disease.Apart from the main tuberculosis unit Tamale), and the district hospital.Specialist services attached to the hospital at Accra, there are chest clinics are available at central hospitals, which serve the atdistrict and other central hospitals where free whole of the region in which they aresituated. treatment is given by medical officers with the advice Laboratory services are provided at all government of the specialist, and where contacts are kept under hospitals and there is a central laboratory at the observation by health visitors and health inspectors. Medical Research Institute in Accra. During 1954, 3503 cases, including 1077 in- patients, Medical fieldunits,with their headquarters at received treatment in hospitals; in 1955 there were Kintampo in Ashanti, conduct campaigns against 879 in- patients. and yaws and control epidemics Cases of venereal disease are treated at all district as they occur.They also survey the incidence of hospitals, and 696 in- patients and 12 572 out -patients disease in rural areas, undertake health education of were attended in 1955 for syphilis and gonorrhoea. the public and administer treatment at fixed centres. As a result of the work of the medical field units, Nine rural health centres had been completed and great progress has been made in recent years in the were in operation by 1956 and 10 more were being control of yaws and in the treatment and control of planned. trypanosomiasis. The total medical and health staff in Ghana in 1955 Smallpox is endemic, and epidemics of varying consisted of 182 registered physicians with British proportions occur from time to time.Vaccination qualifications (104 in government service), 43 licensed is carried out continuously and is performed by many physicians with non -British qualifications, 13 registered different categories of staff; in 1954, 1 041 672 vaccina- dentalsurgeons withBritishqualifications,four tions were performed.Yellow fever surveys carried licensed dental surgeons with non -British qualifica- out in 1954 in seven widely separated areas indicated tions, 221 nurses with British or equivalent qualifica- that, with the exception of one area, there had been tions, 978 nurses with local qualifications, 98 midwives no outbreak for the past twenty years.In one with British or equivalent qualifications, and 421 area in Ashanti the results indicated that yellow midwives with local qualifications.There were in fever was endemic, a finding confirmed by the addition 662 nurses and 156 midwives in training. occurrence of an outbreak in 1955, in which four In 1956 the central government public health services cases were confirmed.Cerebrospinal meningitis is employed the following staff: also endemic, and 136 cases were admitted to hospitals Medical officers 71 * in 1955. Medical officers of health 6 The leprosy service, which has gradually developed Dental surgeons 8 since its inception in 1948, established clinics in diffe- Pharmacists 81 Nurses 693 rent parts of the country in the period under review, Midwives 50 and expanded its staff to provide supervision for these Health visitors 12 clinics, which were in many instances run by medical Excluding specialists or lay auxiliaries.It has now been possible to bring 120 FIRST REPORT ON THE WORLD HEALTH SITUATION treatment more regularly to the patients, of whom subjects in the United Kingdom: dentistry (2), hospital there are approximately 32 000. administration (4), laboratory technology (3), radio- So far as maternal and child health is concerned, graphy (6), physiotherapy (1), ophthalmics (1) and there are four large hospitals in which maternity pharmacy (4). work is a main interest, and all district hospitals Local training for the qualification of State Regis- provide for maternity cases. A large volume of tered Nurse is given at the School of Nursing in Accra, district work is carried out at maternity clinics in and at another school attached to the Kumasi Central both urban and rural areas by midwives under the Hospital.There are six training centres for the Quali- direction of superintendents of health visitors.Child fied Registered Nursing Diploma, which is based on welfare work is carried out at district hospitals; a the apprenticeship system.Four schools provide number of clinics are also held at hospitals, Red midwifery training, two of these (at Accra and Kumasi) Cross centres, health centresor at child welfare being government institutions with 80 and 60 pupils centres, with the co- operation of privatedistrict respectively.Courses for health inspectors are held midwives under the direction of a superintendent of at Accra, Kintampo and Tamale; the course at Accra health visitors. is of three years' duration, and that at the other two The mental hospital at Accra was extended in schools -intended mainly for workers in rural areas - 1954 to house the increasing number of patients.In is of two years' duration.Senior staff nurses are 1955 there were 1030 in- patients; during the year selected for a one -year course to qualify for appoint- 604 were admitted to the hospital and 223 were ment as health centre superintendents. discharged. Health education is provided by health centres and There is as yet no medical school in the country medical field units, and in 1956 an officer was made and, in 1954, 74 students were studying under govern- responsible for the planning of health campaigns ment auspices in the United Kingdom to qualify as throughout the country.Four posts of health educa- doctors. Another 50 were in Germany, sponsored tion officer have also been created to be filled by by the Cocoa Marketing Board.In addition to these, officers who are at present abroad, undergoing special students from Ghana were studying the following courses in this subject.
KENYA (COLONY AND PROTECTORATE)
The Crown Colony and Protectorate of Kenya extend approxi- functioning in small areas.There are five main types of local mately from latitudes 4° north to 4° south and from longitudes authority: the city council (Nairobi being the only example 34° to 42° east.It is bounded on the north by Ethiopia and at present); the Municipal Board; county councils; district Sudan, on the west by Uganda, on the south by Tanganyika, councils and the African district councils in the African areas. and on the east by the Indian Ocean and Somalia. The last- mentioned have powers analogous to those of municipal There is a considerable range of climate.Three zones can and county councils, with authority to raise their own revenue be distinguished: (a) the coast and hinterland, with an average by rates, to engage staff and promote the welfare of the inhabi- temperature of 27° C and an annual rainfall of 100 -125 centi- tants of their areas. metres; (b) the low plains, between 100 and 600 metres above The economy of Kenya rests on agriculture, with some forestry sea -level -mainly dry, with an average annual rainfallof and mining. A high level of investment in industrial and 12 -50 centimetres; and (e) the highlands, where the average commercial enterprise, particularly from overseas,isbeing temperature ranges from 20° C to 10° C according to altitude maintained.The great natural attractions of the country (from 1000 metres to 3500 metres), and the rainfall is between draw tourists.The chief mineral product is soda ash from the 100 and 150 centimetres.The northern part of Kenya is arid mines at Magadi, but deposits of kyanite, graphite and di- and comparatively waterless.The land area is approximately atomite are also worked.African food production varies accor- 563 000 square kilometres. ding to the different ecological zones in the higher areas. Broadly Nairobi, the capital and seat of the Government, is in the speaking, maize, millet, sweet and European potatoes are grown Kenya highlands, about 480 kilometres from the coast.The in the high altitude; maize, beans, bananas, sweet and European 1948 general census recorded an African population of 5 251 120; potatoes and vegetables and colocasia in the grass zone, and European, 29 660; Indian, 90 528 ;Goan, 7161; and Arab, the same crops, together with sorghum, millet, cowpeas and 24175.Estimated mid -year populations for 1952 and 1954 green grain, are produced in the woodland zone.The chief were 5 760 000 and 5 948 000 respectively. domestic exports are coffee, sisal, hides, skins and leather, Kenya is divided into six provinces and the Nairobi extra - wattle extract, tea, pyrethrum and sodium carbonate.Local provincial district.The provinces are divided into districts, secondary industries are developing steadily. each in the charge of a district commissioner.At the next level In 1956 the total enrolment of African pupils at government - are the district officers, both European and African, and below aided and unaided schools (primary, intermediate and secondary) them come the chiefs, sub -chiefs and minor tribal authorities was 446 460, showing an increase of 51 387 over 1955.The AFRICAN REGION 121 number of trained teachers rose from 6118 to 7451.In 1956 The main causes of death among Africans, taken there were over 400 African pupils at the Medical Training from the annual returnof governmenthospital Centre in Nairobi, in addition to 213 Africans at Makerere College in Uganda.There are four trade and technical schools statistics for1956,were: Number % of in the country with an enrolment of nearly 1000 students. of total The number of students from Kenya studying overseas in 1956 deaths deaths reached 1555, of whom 157 were African. Bronchopneumonia 1 166 16.4 There is a Ministry of Community Development which recruits Pulmonary tuberculosis 568 8.0 and trains personnel for, and assists district administrations in, Gastro- enteritis and colitis (between 4 weeks community development projects, trains African chiefs, local and 2 years of age) 433 6.0 leaders and specialized staff employed by other government Lobar pneumonia 365 5.1 departments or local governments, and encourages voluntary Kwashiorkor 225 3.2 organizations for community development.Responsibility for Tetanus 211 3.0 social welfare rests with the Ministry of Health. Typhoid 191 2.7 Pneumococcal meningitis 176 2.5 Burns 158 2.2 Health Meningococcal infections 156 2.2 Malaria 156 2.2 The Central Medical Department, under a Director Gastro -enteritis and colitis (2 years of age of Medical Services, is responsible for formulating and over) 147 2.0 medical and health policy, for the control and treat- Total 3 952 55.5 ment of infectious diseases and for the administration of government,provincial and districthospitals. Hospitals can be divided into four groups: (1) Afri- The department includesa deputy director,two can government hospitals (of which the main one assistant directors, seven senior medical officers and is King George VI Hospital in Nairobi), staffed by 10 specialist officers.In1956the number of medical specialists,registrarsandinternsandproviding officers was increased by 11, bringing the total to91. special forms of treatment. (2) Provincial hospitals There are two parallel systems of public health (of which there are four - at Nyeri, Nakuru, Kisumu service, each related to a different form of local and Mombasa), each staffed by a physician and government.Municipal councils and county councils surgeon with specialist qualifications, and supporting are responsible directly to the Ministry of Health staff.(3)Specialhospitals, which consist of the for all normal local health services, consisting prin- Mathari Hospital for Mental Diseases, Nairobi, the cipally of ante -natal and child welfare, maternity Orthopaedic Hospital, Nairobi, the Infectious Diseases care, infectious diseases control, day nurseries and Hospital, Nairobi, Port Reitz Chest Hospital, Mom- nursery schools, and environmental sanitation. basa, and the Itesio Leprosarium, Elgoy Nyanza In African district council areas, the district coun- District.The Infectious Diseases Hospital, Nairobi, cils are the public health authorities; senior and super- has accommodation for general infectious diseases, visory staff are supplied by the Government.The tuberculosis, and a special unit equipped to treat all services provided consist of comprehensive maternity types of poliomyelitis.(4)District hospitals, of which and child welfare (including institutional and domi- there are 52 (main and subordinate).These govern- ciliary midwifery based on hospitals and health ment hospitals provide a bed /population ratio of1.2: centres, and in some cases dispensaries); control of 1000. infectiousdisease,environmentalsanitation,and Further African accommodation isavailable in ambulance services. 16mission hospitals:six in the Central Province, In1956, 1.7per cent. of the gross domestic income two in the Coast Province, two in Rift Valley Province, was allocated to health.The per capita cost of one in Southern Province, and five in Nyanza Province. over -allhealthservices was8/- (US $1.12),being Every main district hospital includes an African approximately2/4 (US $0.32)for administration and district council maternity ward.The municipalities preventive medicine services and5/8 (US $0.79)for of Mombasa, Nairobi, Nakuru and Kitale and the medical care. county councils of Nakuru and Naivasha operate Registration of births and deaths is compulsory their own African maternity hospitals or maternity for Europeans and Asians in both rural and urban ward units. areas, while registration of deaths of Africans is There are eight European hospitals, provided by compulsory onlyin urbanareas.Four African the European community and controlled independ- district councils have passed by -laws for the compul- ently.Two of these are in Nairobi, and Mombasa, sory registration of births and deaths in their areas, Nakuru, Nyeri, Nanyuki, Eldoretand Kitale have one whilst others are proposing to follow their example. each.The Government also runs one hospital for 122 FIRST REPORT ON THE WORLD HEALTH SITUATION for Europeans, at Kisumu.Further accommodation Considerable progress has been made in the exten- for Europeans is available at the Port Reitz Chest Hos- sion of rural health services through the establishment pital, the Infectious Diseases Hospital,Mathari Hospital, of health centres, of which there are two types :the and the Consulata Catholic Mission Hospital, Myeri. main health centres (12 in number), integrated with There are three Asian hospitals - the Pandya the service of selected district hospitals, and the Memorial Clinic, Mombasa, Rahimtulla Indian Mater- "locational" health centres, built with the co- operation nity Home, Mombasa, and the Aga Khan Home, of the local authorities, mainly the African district Kisumu.Accommodation is also available for Asian councils.The locational health centres, 33 of which patients at the King George VI Hospital, the Infectious had been completed by 1956, are staffed entirely by Diseases Hospital, the Mathari Hospital, the Port Africans, the aim being that at each there shall be Reitz Hospital, as well as at three provincial and nine an African medical assistant in charge, with an district hospitals.The Social Services League, an assistant health inspector, midwife and health visitor Indian welfare association, runs an Indian maternity as a minimum.Facilities in these health centres also hospital at Nairobi, and the Ismailia community includeadomiciliaryserviceformaternity and have built the Aga Khan Hospital for all races. sickness, and child welfare clinics. Tuberculosis remains one of the most important The training of local personnel is undertaken by communicable diseases, and the Infectious Diseases government and municipal authorities and mission Hospital and the Port Reitz Chest Hospital, together hospitals.At the Government Medical Training with the provincial hospitals of the Central Province, Centre in Nairobi, more than 400 African students Rift Valley Province and Nyanza Province, form main are undergoing courses of training as hospital and centres for the tuberculosis service; they are used laboratory assistants.In 1956 the training of medical for in- patient treatment, radiography, and assessment, assistants was also commenced at this Centre.The and supply a general consultant service.Twenty -two basic standard of education is higher than that required main district and subordinate hospitals have an for hospital assistants, and the standard of medical averageof 10 -12 bedsreserved fortuberculosis training given will accordingly be much higher.In patients, and form centres for the district service. addition, the training of health visitorsis carried The total number of beds in government hospitals avail- out at two rural centres.There are also 10 medical able for Africans with tuberculosis is 636; for Asians, mission training centres for nurses and midwives, 56; and for Europeans, 16. A number of mission and three municipal and other hospitals at which hospitals also have beds reserved for this disease. African and Asian midwives are trained. A Nurses' Clinicsfortuberculosispatientsreceiving out- and Midwives' Council has been established and is patient and domiciliary treatment are held regularly recognized as the statutory body for the training and in nearly every hospital in the territory, at health registration of nurses, assistant nurses and midwives centres and at some dispensaries; this form of treat- in Kenya. ment was established as a firm policy of the Govern- A considerable contribution to medical research ment in 1956, when a tuberculosis field officer was in East Africa is being made, under the aegis of the appointed to control this work. East Africa High Commission, by the Council for Malaria may generally be said to be endemic to Medical Research for East Africa, which has four main hyperendemic inthecoastal area and the Lake inter- territorial centres - two in Tanganyika, one in basin, and epidemic in the highlands, where, however, Uganda, and the Leprosy Research Institute in Kenya. itislargely controlled.Control measures against Much research isalso done by the Division of this disease and against bilharziasis are given con- Insect -Borne Diseases in Nairobi on problems such siderable attention by the Government, especially in as kala -azar, malaria, relapsing fever, bilharziasis and resettlement and irrigation schemes in the Rift Valley filariasis, and in Kenya itself a number of individual and the Central Provinces. workers conduct investigations in various fields.
LIBERIA
The Republic of Liberia is situated on the bulge of tropical 300 to 380 centimetres and there are two distinct dry and rainy West Africa, about 4° north of the equator. Itis generally seasons in the year. plateau land, rising gradually from the coast to the interior, Liberia is bounded on the east by the French Ivory Coast, where a mountainous range reaches the height of 1000 to 1200 on the north by Sierra Leone and former French Guinea, and metres above sea level.The average annual rainfall ranges from on the south and west by the Atlantic Ocean.The land area AFRICAN REGION 123
is110 000 square kilometres, with a population of about there were 40 physicians in government service and 2 500 000 divided into numerous tribal groups speaking different 65 in private practice. dialects; English is, however, used as the official language. The country is divided into five counties and three provinces, In 1946 the national budget for health was little which in turn are subdivided into districts and chiefdoms. more than US $100 000; in 1956 it was over US On the whole, the Liberians are an agricultural people and $2 000 000. depend on the land for their livelihood.Rice is the principal There has not so far been an official census of the grain crop and forms the main diet.Cassava and other starchy roots are found throughout the country, and form part of the population of Liberia, but during the period under staple diet.The coast tribes rely on fish for most of their review plans were made for a census to be taken in protein, while the people of the interior depend on wild game 1958; the Census Advisory Committee which was to and livestock.Bananas, oranges and other tropical fruits are be appointed was to include at least one member found in abundance. of the National Public Health Service. Since 1947, the Liberian Government has taken important No uniform steps to extend the educational system.All mission schools are system of recordingvitalstatisticshas yet been granted subsidies and all government schools are free up to established, but plans were under way to train per- college level.There are now government schools in all the sonnel in the recording of births and deaths within chief towns. the structure of the government services, so that eventually a complete service may be available for Health the whole country. Smallpox, which used to be present in epidemic The geographicalpositionofLiberiapresents form and cause many deaths, is now fairly well under considerable difficulties in overcoming the numerous control.There is a strict system of reporting, and publichealthproblems.Densetropicalforests, a vaccination programme.Malaria is still the most together with heavy rainfall, create many streams and serious public health problem, but it is being attacked swamps, and the climate is favourable to the existence through residual spraying and chemoprophylaxis. of harmful insects and parasites.Very few accessible Yaws, which was the problem second in importance, roads exist in the country, a handicap which the is now practically eliminated through the use of Government is endeavouring to overcome. penicillin in a nation -wide campaign. The Health Department, known as the National Trypanosomiasisisfoundparticularlyinthe Public Health Service, is headed by a Cabinet Minister Western Province and parts of the Central Province. with the technical title of Director -General of Health. For its control, the Government is training technicians It has two main divisions- hospitals, and health and toundertake surveys,give treatment to infected sanitation -each under the charge of an Assistant persons.Plans are now under way for an eradication Director -General.All public health and medical campaign. services fall within the scope of activities of these Tuberculosis does not seem to be a very serious two divisions.There is a school of nursing directly scourge at present; all known tuberculosis patients under the supervision of the Director - General.Each are flown to Congotown and cared for in the sana- of the three provinces has a Provincial Director of torium there. Health and each of the five counties has a County There are five settlements for the care of leprosy Director of Health. patients, with a total of 2000 patients under super- Until1947healthfacilitieswerenon -existent vision and treatment. outside the capital city, Monrovia.In 1947 there The Dyer Memorial Maternal and Child Welfare were not more than 200 hospital beds in the entire Centre in Monrovia is run by the Government, and country, and the people were accustomed to put includes a maternity hospital; during the 12 months their faith in superstition and witch doctors.In 1956, ended September1956,308pre -natalvisitsand there was at least one hospital in each of the five 471 deliveries were recorded, and 498 babies were counties and each of the three provinces, with a total seen at infant welfare clinic sessions. of about 1000 beds.The government hospital in With regard to health education, efforts are being Monrovia has about 350 beds, including the maternity made to provide school- teachers during their course unit; the tuberculosis hospital in Congotown has of training with sufficient knowledge to enable them about 100 beds and there are six other government to carry out health teaching in primary schools. hospitals in the more important towns.In addition, Courses in health education have also been prepared the Firestone Plantation maintains a general hospital. for the UNESCO Fundamental Education training There is a public health clinic in each principal town project near Monrovia. throughout the country.All mission hospitals or For the training of doctors there is a long -term clinics are subsidized by the Government.In 1956 fellowship programme, consisting of both govern- 124 FIRST REPORT ON THE WORLD HEALTH SITUATION ment and WHO fellowships,toenable Liberian in recruiting students for the school.The midwifery studentstotakeundergraduatemedicalstudies training programme is under the school of nursing. abroad.By the end of 1956, 21 Liberian medical There are four training centres, two of them for students were studying in Belgium, England, Egypt, literate and two for illiterate midwives.The two Germany,theNetherlands,Switzerland and the latter schools are located in the Central and Western United States of America.By 1960 it is expected Provinces. that fully qualified Liberian physicians will begin to A five -year plan, which is being drawn up for the be available to strengthen the health services of the development of the health services, includes a co- country. ordinated scheme for the location and size of hospitals The school of nursing in Monrovia, which was and other health establishments.The terms of the established with assistance from the United States planwillgoverntheoperationoftheentire of America early in 1950, is now training an average National Public Health Service - its organizational of 20 students a year, and has an annual output of structure, staffing arrangements, and all public health about eight graduates.There has been difficulty activities.
MADAGASCAR
Madagascar is situated off the south -east coast of Africa, divided into medical districts, each of which is under separated from it by the Mozambique Channel, which is about the charge of a medical officer.There were 31 such 400 kilometres wide.It is the third largest island in the world, with a coastline of some 7500 kilometres and an area of 590 000 districts in 1956. square kilometres.Tananariveisthecapital.The island In Tananarive there are two general hospitals - consists of various geographical regions differing widely in the Colonial Hospital and the main Government relief, soil geology, climate and vegetation.Except in the south- hospital - as well as a special children's hospital. west, it is well watered. There are four distinct climates: east, central and west, be- The Institute of Social Hygiene isresponsible for coming progressively drier, and a warm sub -desert in the extreme thecontrol of malaria, tuberculosis, leprosy and south and south -west.The centre is cooler and frost is known venereal diseases, and fororganizingtheschool above 1500 metres. medical services, and the healthvisitors'school. In 1955 the total population was estimated at 4 777 225; non - There isalsoa Pasteur Institute, which includes indigenous inhabitants included about 66 089 French, 3417 other Europeans, and 21 346 Asians. a central anti -plague service and a central phar- The widely differing geographical regions provide a great macy. variety of resources and a large range of export commodities. Apart from the province of Tananarive, which is The principal agricultural products in 1955 were manioc, served by the central health establishments in the sugar -cane, maize, tapioca and batata.Graphite, mica and capital, each of the five other provinces has a general precious stones are mined.The forests contain many valuable woods, and rubber, gum, resins and plants for tanning, dyeing hospital, and each of the medical districts has one and medicinal purposes abound.Cattle -breeding and agricul- or more district hospitals.In 1956 there were 61 ture are the main occupations of the indigenous population. district hospitals, as well as 277 medical centres, The chief imports are foods, metals, cement, fuel, machinery 314 maternity centres (not including the maternity and cotton. The territory is divided into six provinces, which are adminis- departments of the larger hospitals), 88 dispensaries, tratively and financially autonomous.Each province is divided one psychiatric centre, and 16 leprosy settlements. into districts and subdivided into governments, cantons and Other specialized services included venereal disease villages.Village chiefs and notables, who do not take part in control (at 11 centres), and 53 quarantine stations the administration proper, are designated by the population. There is a traditional village organization, the Fokon Olona, for travellers by sea and air, as well as for local which is being modernized and used by the Government to cases of infectious disease.Several mobile health encourage social and economic development of the rural areas. teams,operatingatprovincialordistrictlevel, Education is compulsory and free. provide health services fortherural population, and the Fokon Olona also has a share in health Health work. The Public Health Service consists of a central The staff of the Public Health Service in 1956 Directorate at Tananarive and a main office in the consisted of 283 European and 2120 indigenous capital of each province.The provinces are sub- personnel, distributed as follows: AFRICAN REGION 125
Category EuropeanMadagascan Total they are contagious, and domiciliary treatment is en- Physicians: couraged. A tuberculosis control programme has with French State degrees . 94 18 112 with Madagascan degrees . 318 318 been started by thecentraltuberculosisservice, - and isbeing carried out through the tuberculosis Pharmacists: with French State degrees. 13 3 16 dispensary and the mobile health units, which are with Madagascan degrees . 15 15 equipped for mass x -ray examinations. Dentists: * Special emphasis is being laid on maternal and with French State diplomas . 2 2 childhealth.In1956,185 576 pregnant women Midwives: received ante -natalcare, and there were 123 884 with French State diplomas 15 3 18 hospital deliveries and 3014 home deliveries during with Madagascan diplomas 380 380 the same year.Post -natal care was given to 121 352 Nurses (male and female): mothers, and infant and child welfare clinics provided with French State diplomas 78 78 care for 427 986 infants under one year of age and with military diplomas . 49 49 481 761 children between one and four years.Medical locally trained - 1 257 1 257 supervision of older children is carried out by the Health visitors 93 93 school health service. Malaria inspectors 33 33 A special section was set up in 1955 to carry out
Mobile health team leaders. 32 32 research on feeding and nutrition, and the first surveys have been undertaken in the northern suburbs of Total 283 2 120 2 403 Tananarive. Dentists trained at the Tananarive Medical School are included in the The School of Medicine and Pharmacy in Tananarive 318 physicians with Madagascan degrees. provides a five -year medical course for physicians (including one year of pre -clinical studies) leading In 1956, 9.68 per cent. of the total budget of the to a medical diploma which qualifies graduates to territory was devoted to the medical and health work in the territorial Medical Service; it also provides services. a four -year course for pharmacy students (including The popularity of theterritory's medical care one preparatory year) leading toa pharmacist's servicesisillustrated by the returns from health diploma and thence to appointment as a pharmacist establishmentsin1956.Theestablishmentsdes- in the territorial Medical Service.The school also cribed above provided a total of 12 207 beds and has a stomatological centre, which organizes a two - recorded 203 456 in- patients during the year.Over year course for dental mechanics.The Tananarive four million people visited the out -patient departments Midwifery School has a three -year diploma course of hospitals, medical centres, dispensaries, etc., the for midwives, and the Health Visitors' School also total number of out -patient visits during the year gives a three -year course ending with a qualifying being 8 898 652, and mobile health teams recorded examination. A Nursing School was opened in over 500 000 more consultations. Tananarive in 1954; it offers a two -year course and The reported death rate in 1956 was 12.6, and the is organized on the same lines as nursing schools infant mortality rate was 78.0.The main causes in France, awarding a diploma of the same standard of death among cases treated in the hospitals in 1956 as the French State diploma.Nursing courses are were diseases of the respiratory and digestive tracts. also organized at the two main general hospitals These were also the most important diseases treated in Tananarive and at the provincial hospitals.Other inthemedicalcentresand dispensaries.Other types of training include a six -month course for malaria prin iç pá1 disuses_ rented were: _ma aria, helminthiasis, inspectors,a one -year course of specialization in eye diseases, and skin conditions. various subjects for nurses, and a one -year course As a result of the control campaign launched some for prosthetic technicians.In 1956, graduates from Z years ago, malaria is no lonier common in the island. the School of Medicine and Pharmacy and from Twenty cases of plague with 11 deaths were reported auxiliary training schools included:18 physicians, in 1956; 799 907 inoculations against plague were three pharmacists, 24 midwives, 13 health visitors, carried out.Leprosy cases are not segregated unless and 42 nurses. 126 FIRST REPORT ON THE WORLD HEALTH SITUATION
MAURITIUS AND DEPENDENCIES
Mauritius is an island in the Indian Ocean about 20° south of In 1957, the following medical and health personnel the Equator.The area (including a number of islands - or were working in the territory, either in government " dependencies "- scattered in the Indian Ocean) is 2096 square service or in private practice : kilometres.The highest point is 826 metres above sea level and there is an elongated central plateau at 550 -580 metres which GovernmentPrivate slopes gradually to the sea on the south and south -east.Port Registered physicians 73 60 Louis is the capital.The climate is comparatively mild and Principal matron 1 - equable for the latitude, with an abundant but variable rainfall. Matrons 4 The estimated population at the end of 1957 was 596 621. Senior nursing sisters 5 Nurses in hospitals 192 The larger urban areas of Mauritius have had their own local Dressers in hospitals 222 government for many years.Local government in rural areas Superintendent of midwives 1 was started in 1946.By 1952 the number of village councils Midwives 65 had increased to 90.Three district councils have since been Sanitary inspectors 59 - set up to advise the district civil commissioners on matters of X -ray specialists 2 2 policy. Assistant radiologist 1 -- The island's economy depends on sugar, which accounted X -ray technicians 5 - for 97 per cent. of the exports in 1954.The subsidiary crops Pharmacists 2 42 are tea and aloe fibre, the production of which is increasing. Dentists 4 26 The island is largely dependant on imported food.There is a ten -year development programme for agriculture, education, health and nutrition, sewerage and water supply, roads and Medical personnel are trained overseas.With a buildings, the sugar industry, and research. few exceptions auxiliary personnel are trained locally. Education isfree and not compulsory. Scholarships are In order to meet the needs of the expanding health available for free secondary education.Language is a particular services, efforts are being made to train more health problem; English and French are compulsory subjects and workers, including specialists, by offering scholar- Hindu, Tamil, Hakka and Chinese are optional in the schools. ships and fellowships. The population uses a lingua franca based on French and known Notification and registration of births is compulsory. as " creole " and, although it is not officially encouraged, its use in Medical certification of causes of deaths is in force the classroom as a vehicle of expression is common. only in the districts of Port Louis and Plaines Wilhems, and covers just under half of the population.The Health birth rates for 1954 and 1957 were 41.3 and 43.1, and the recorded death rates in the same period were The Public Health Department is under the Director 16.0 and 13.0.The infant mortality rate has dropped of Medical Services, who is assisted by two deputy - from 81.1 in 1954 to 75.1 in 1957. directors.The departmentisdivided intothree There was an outbreak of Asian influenza in 1957. main divisions :administration, public health, and However, vigilance is maintained to prevent the return curative and diagnosticservices.Thelatterare of communicable diseases once prevalent in Mauritius. subdivided into the hospital and dispensary service Vaccination against smallpox is compulsory; whoop- and the laboratory service. ing -cough and TAB vaccines are available free of There are eight public hospitals, with a total of charge.Malaria has been practicallyeradicated. 1202 beds; an orthopaedic centre, with 156 beds; Venereal disease cases are treated at all hospitals a mental hospital, with 707 beds, and a settlement and dispensaries. BCG vaccination is included in the for leprosy patients, with 62 beds.In addition to tuberculosis control programme of the Health De- 48 out -patient clinics, there is a mobile dispensary partment and by the end of 1957, 25 749 children had service comprising four units and attending to the been vaccinated.Intestinal diseases are still a serious needs of 64 villages.The first chest clinic is nearly problem and health education of the population is completed and a second chest clinic and a tuberculosis proceeding with special reference to this problem. hospital will be constructed in the near future.There Vaccination of the most vulnerable groups of the are 16 centres specially concerned with maternal and population against poliomyelitis started at the be- child health, each of which provides a district midwifery ginning of the 1957 summer season. service, and there are also two midwifery services Water supplies are gradually being improved, and based on two of the hospitals. A full school medical by 1958 every resident of Mauritius will have at his service is in operation. disposal filtered and chlorinated water.Fluoridation AFRICAN REGION 127 of one of the main supplies will become effective by A new five -year health programme of expansion the end of 1957 or early 1958. and development was approved in1956, and is Malnutrition isat present an important concern already being carried out.This programme covers of the health service, the most current deficiencies the need for additional hospital beds, expansion being in protein and iron.All children attending of thematernal and childhealthservicesand primary schools receive food supplements during of theout -patientfacilities,andtheestablish- the mid -day breaks. ment of a new public health laboratory.Italso A special unit, which has x -ray therapy machines and includes the modernization of equipment, improve- radium at its disposal, is engaged in the treatment ment of the ambulance service, and staff housing and control of cancer. facilities.
MOZAMBIQUE
The Portuguese Province of Mozambique is on the east coast Each district health service is provided with the necess- of Africa and lies between latitudes 10° and 27° south.It is ary nursing staff, and has a regional nursing station bounded on the north by Tanganyika, Nyasaland and Northern Rhodesia, on the south by Natal (Union of South Africa), on or small hospital and one or more maternity centres the west by Lake Nyasa, Southern Rhodesia, Transvaal, and associated with health units.The latter are run by Swaziland, and on the east by the Indian Ocean.The total male nurses, and sometimes also include an auxiliary area is 771 125 square kilometres.At the 1950 census the midwife; they are visited periodically and at fixed population was 5 738 911; in 1955 the non -indigenous population times by the district medical officer. numbered 117 405. For administrative purposes the Province isdivided into Preventive and curative medical care is provided districts, each under a local governor, and subdivided into through hospitals, nursing stationsor aid posts, councils or boroughs; all are under the authority of the Governor - and other health establishments run under either General, whose seat is the capital, Lourenço Marques. government or private auspices.Home care is also Mozambique is essentially agricultural, although industrializa- necessary.In1956,government tion is taking place slowly.The principal products are cotton, provided when maize, groundnuts, palm oil, tobacco, sugar, sisal and tea, all health establishments included two central hospitals of which are exported. (one in Lourenço Marques and one in Beira), 10 regionalhospitals,53regionalnursingstations, Health 203 health units, 89 rural maternity centres, seven leprosaria, two tuberculosis dispensaries,15 infant The health services of Mozambique were reorganized welfare centres, 12 pre -natal clinics, and 66 leprosy in accordance with a Decree of 1945 concerning all out -patient dispensaries.Private institutions in the the Portuguese overseas provinces.At the central same year included six nursing homes, one maternity level, the health services are administered by a Direc- centre, 13 hospitals, six medical stations, 145 health torate of Health, which comprises three departments - units and 172 ambulances with first -aid posts. medical, pharmaceutical and administrative.Asso- The following medical and health personnel, both ciated with the Directorate are a number of bodies government and private, were working in Mozambique - some of an advisory nature, such as the Public in 1956: 276 physicians, 143 pharmacists, 450 male Health Council; others with executive functions, such nurses, 232 auxiliary nurse -midwives, laboratory and as the services for the control of leprosy, tuberculosis, pharmacy assistants, and nurses in the service of malaria, and trypanosomiasis, and for mental health, missions, etc. social welfare and maternal and child health. Training of nurses, auxiliary midwives and labo- For health administration the Province is divided ratory and pharmacy assistantsisundertaken in into four health regions, nine health areas and 76 technical schools, which are under the administration district health services, with medical officers of differ- of the health services, and which in 1956 trained ent categories in charge at each level.Each health 130 male nurses, 50 auxiliary midwives, nine laboratory region is under the direction of a medical inspector, assistants and eight pharmacy assistants. whose chief task is to guide and supervise the activities In the control of communicable diseases, the follow- of the district medical officers.The district health ing developments are particularly noteworthy. services are in the charge of medical officers (categories Leprosy control has been intensified, through case - I or II) who are under the direct supervision of the finding surveys, improvement of existing leprosaria, chief medical officer of the health area concerned. the setting -up of special dispensaries for ambulatory 128 FIRST REPORT ON THE WORLD HEALTH SITUATION
treatment of leprosy patients, and the large -scale Large -scale campaigns are being conducted against application of modern chemotherapy. yaws, venereal diseases and mycosis.In the latest A campaign for the control of tuberculosis was yaws control campaign 31 195 patients were treated. conducted in 1954 and 1955, during which 8000 medical Ninety per cent.of the indigenous population examinations and more than 60 000 x -ray examinations suffer from helminthiasisMeasures adopted in an were carried out, and treatment was given to confirmed effort to control these infestations include continuous cases. anti -parasitic measures, health education, and im- Measures for malaria control have been in operation provement of diet. for more than twenty years, and are continuing; it is There is a good maternity service in Mozambique, hoped that the incidence may at least be reduced, but it needs to be developed in order to become even if complete eradication is not possible.Efforts even more efficient and useful.The first hospital have been concentrated chiefly on control in urban delivery in the Province was recorded in 1899, but not areas, and the disease has almost disappeared in those until 1922 were any steps taken to organize maternal places where treatment has been most intense.In and child welfare services, and the first pre -natal 1955, spraying operations covered some eight million services started in 1927.Since then, assistance to square metresof malarious country, and about mothers before and after child -birth has gradually 190 000 dwellings. increased, and in 1955, 34 217 pre -natal and post -natal The fight against trypanosomiasis is continuing. visits were recorded. The tsetse fly is one of the most complex problems Many rural areas have sanitation facilities and in Mozambique, since about 400 000 square kilo- water -supply systems.The installation of latrines metres of the territory are infested with Glossina has been undertaken on a large scale in rural areas. palpalis. A special body has been set up for the The inhabitants are shown how to construct them. control of both human and animal trypanosomiasis. Health education campaigns among the African Smallpox is not a public health problem.Only population aim at improving environmental sanitation a few cases are recorded each year, and large -scale and encouraging the development of new housing vaccination is carried out; during the past five years, schemes.Great effortsare being made toraise six million persons have been vaccinated or re- vacci- the standard of living of the African population, nated, 1 150 000 in the last year alone. particularlytheirnutritionalstatus and levelof Both vesical and intestinal bilharziasis are wide- personal and collective hygiene, and the preventive spread; 26 679 carriers of the former and 789 of the and curative health services are contributing to the latter were treated in 1956. success of these efforts.
FEDERATION OF NIGERIA
Nigeria, situated in West Africa, is bounded on the south Region, with regional headquarters at Kaduna, Enugu and by the Gulf of Guinea, on the west and north by Dahomey Ibadan.In 1954, the country became a Federation; the Federal and French Niger and on the east by the Cameroons under Capital is at Lagos, which, including the Lagos Islands, forms French administration. the Federal Territory.The total population at the 1952 -53 A belt of mangrove swamp 16 to 96 kilometres wide lies census was 31 200 000, divided between the Northern Region along the whole sea coast.To the north there is a zone 80 to (16 800 000), the Eastern Region (8 000 000), and the Western 160 kilometres wide of tropical rain- forest and oil -palm bush. Region (6 400 000).The Federal Territory of Lagos had a North of that again the land rises and becomes open woodland population of 312 000. and savannahIn the extreme north the country is almost desert. There is a Council of Ministers for the Federation and Exe- There are few mountains in Nigeria except along the eastern cutive Councils for the three regions and for the trust territory boundary. of the Southern Cameroons.Local government is the main The climate varies according to these zones, but everywhere responsibility of a large number of indigenous administra- it is tropical and temperatures are high; humidity is high at tions. the coast and falls off northward.The rainy seasons is from The economy of Nigeria is predominantly agricultural.The May to October; the annual rainfall ranges from under 65 centi- principal farm crops are cassava, yams, guinea corn, millet, metres in the extreme north to 380 centimetres on the eastern coco -yams and maize.The chief tree crops are palm kernels coastline.During the dry season the hot and dusty harmat- and cocoa.About 96 per cent. of the livestock is found in tan blows from the desert in the north. the Northern Region.The cattle are kept partly by nomads Including that part of the Cameroons which is a trust territory and partly by more settled people who, according to the season, administered by the United Kingdom as part of Nigeria, the migrate only between the savannah and river grazing- grounds. area is about 995 500 square kilometres.Nigeria is divided Mass immunization of livestock is necessary to keep down into the Northern Region, the Eastern Region and the Western disease.Forestry is productive only in the coastal rain- forest. AFRICAN REGION 129
The smaller trees of the savannah are necessary for soil con- have been decentralized into four separate services: servation. the Federal Medical Service, and those of the Western, The principal mineral products are coal, tin ore and columbite. The Geological Surveys Department has recently investigated Northern and Eastern Regions.The Federal Medical coal -fields, iron ore deposits, columbite, limestone and ground- Department is under the direction of the Chief Medical water.Further deposits of columbite were found. Adviser, who is responsible to the Federal Minister The increasingly favourable trade of recent years and grants of Social Services, and is assisted by a deputy.In from the United Kingdom Colonial Development and Welfare Fund have greatly helped economic development. An economic addition to services for the whole of the Federation, programme of the Government of the Federation of Nigeria the Federal Ministry is also responsible for the health 1955 -60 was approved by the House of Representatives in 1956. services of the Federal Territory of Lagos and of the The programme makes a capital provision of £2 591 000 trust territory of the Southern Cameroons, which is (US $7 254 800) for 1956 -60 with resultant additional recurrent under the direction of a principal medical officer.In expenditure of £271 000 (US $758 800) per annum. Each Region has a Director of Education who, under the 1955 the staff of the federal medical services included regional Minister for Education, supervises generally the work a chief pathologist for the federal laboratory service, of the regional Department.Primary education is the res- a senior pathologist for the forensic science laboratory, ponsibility of indigenous authorities, local government councils, a senior malariologist for the federal malaria service, and voluntary agencies (mostly missions).In the Western Region universal free primary education came into effect in a chief pharmacist, a medical statistician, an adviser January 1955, and the Eastern Region will soon follow suit. on nutrition, a principal matron, a port health officer Handicraft centres give training for senior classes in primary (Lagos and Ikeja), an airport medical officer (Kano, schools and part -time trade or craft training for adults.Trade Maiduguri and Calabar), and a senior medical officer centres provide courses of from three to five years' duration for Lagos Territory. for selected apprentices who have completed primary school education. In each region there is a Director of Medical Ser- At the Nigerian College of Arts, Science and Technology, vices, assisted by a Deputy Director, a senior health professional training was proposed (1954) for civil, mechanical, officer and a matron.The Director of Medical Ser- electrical and mining engineers,architects, landsurveyors, vices is responsible to the regional Minister of Health, pharmacists, secretaries, accountants and specialist teachers. The University College, Ibadan, comprises faculties of arts, who in turn is responsible to the Executive Council of science, agriculture and medicine and has over 500 students the regional government. in four residential colleges. A large number of students, some The local unit of administration in each region private and some officially sponsored, study overseas. isthe medical area, which usually coincides with The Adult Branch of the Education Department aims at one or more administrative divisions.Itis based promoting adult literacy and civic consciousness, and at pro- ducing visual aids, literature, and practical demonstrations. on a general hospital and isin the charge of a The West African Institute of Social and Economic Research medical officer responsible for both medical and was set up in 1950.Its headquarters are attached to University health work in his area.Medical areas are grouped College, Ibadan, and its aim is to co- ordinate social and economic into medical divisions which cover two or more research in British West Africa. The communities range from large towns to villages and there provinces and are under the charge of senior medical are some nomadic tribes in the north.Adobe construction officers. is still the most common for buildings outside the larger towns. Since 1954, the three regional governments have In several areas villages are being replanned and there are been virtually autonomous in medical and health building plans and regulations for most of the towns.Develop- matters and publish their own separate annual reports. ment grants are used for self -supporting housing schemes. Advice is obtained from the building research stations at The Federal Government, however, retains exclusive Watford, England, and at Accra, Ghana, and the Tropical legislative powers over the following subjects, which TestingEstablishment,PortHarcourt.Modernbuilding have a bearing on health: the census; the University techniques are taught in trade training centres. College Teaching Hospital at Ibadan; the School of There are various seasonal movements of labour.Farmers go to the towns to work for short periods and return to their Pharmacy; port health work and quarantine at sea- farms.Well -paid seasonal work, such as cocoa harvesting, ports and international airports; and external relations. draws unskilled labour from the towns and leaves some urban The regional governments have legislative powers areas short of labour for building and road -making.There concurrent with those of the Federal Government, are also movements of labour in the timber industry in the Western Region and in tin mining in the Northern Region. which, however, has over -riding powers whenever Nigerian labour is recruited for work in the Spanish territories federal and regionallegislationconflict,onthe of the Gulf of Guinea and in Gabon in French Equatorial subjects of the control of dangerous drugs; prisons Africa. and other institutions for the treatment of offenders; quarantine; scientific research; statistics; and pro- Health fessionalqualificationsof personnel inmedicine, Since the adoption of the Constitution of the Federa- dentistry, veterinary medicine, pharmacy, nursing and tion of Nigeria on 1 October 1954, the medical services midwifery. 130 FIRST REPORT ON THE WORLD HEALTH SITUATION
Training facilities under federal control for medical of University College Hospital) in the West, at Kano personnel comprise the following: the Faculty of and Wusasa in the North, at Enugu, Aba and Iyi -enu Medicine at University College, Ibadan; the School of in the East, and at Victoria in the Southern Cameroons. Pharmacy; the School of Dental Technology; the Hospital training for successful student nurses is given School for Dental Hygienists; the School of Radio- at two hospitals in Lagos, 13 in the Northern Region, graphy; the School of Physiotherapy, and the School 15 in the Eastern Region, 12 in the Western Region, of Medical Laboratory Technology.In addition to and two in the Southern Cameroons.These 44 hospi- these institutions, which accept students from the tals, which are approved by the Nursing Council and whole Federation, the regions have their own training the Midwives Board, train a total of about 500 nurses facilities for nurses, midwives, sanitary inspectors and and midwives annually.Each region, and Lagos, health visitors.The training syllabus and examina- has its own School of Hygiene for the training of tion of nurses and midwives are, however, federally sanitary inspectors and health visitors.The West controlled by the Nigerian Nursing Council and the African Examination Board of the Royal Society of Midwives Board respectively. Health holds annual examinations for the Society's University College, Ibadan, which isinspecial Certificate in Lagos and Kano. relationship with London University,providesa Government medical and health staff in 1956 were three -year pre -clinical course for medical students; as follows: Northern EasternWestern the clinical course, also lasting three years, is at present Lagos RegionRegionRegion Total taken at London University and leads to the London Medical officers . . . 68 73 66 66 273
M.B., B.S. degrees.Clinical teaching was to be under- Dental officers . . . . 7 3 3 9 22 taken at Ibadan on completion of the University Nurses and midwives 531 416 461 592 2000 College Hospital in 1958, with an expected annual Pharmacists 58 53 74 47 232 output of about 50 doctors.In addition, there were Laboratory technicians 13 18 10 11 52 Radiographers and phy- 60 medical students studying abroad in 1955 on siotherapists . . . . 11 6 7 2 26 government scholarships. The School of Pharmacy of Yaba, Lagos, has an The total estimated expenditure on federal medical annual intake of 40 students, and offers a three -year and health services for the fiscal year 1 April 1956 course with a syllabus almost identical with that to 31 March 1957, was £1 201 860 (US $3 365 208). used for the pre -1948 qualification (M.P.S) of the In addition, for the same period, the health expenditure Pharmaceutical Society of Great Britain.It is pro- under the economic programme, which includes the posed in 1958 to transfer this school to the Nigerian building of three new dispensaries, three maternal College of Arts, Science and Technology, which will and child health and school clinics, a new general teach a four -year syllabus leading to the B. Pharm. hospital of 600 -bed capacity, a new 150 -bed maternity degree.The Yaba school will then train a lower hospital and trainingfacilitiesforradiographers, grade of dispensing assistants. dental technical assistants, dental hygienists, assistant The School of Dental Technology was enlarged in physiotherapists and medical laboratory technicians, 1955, and now accepts 20 students.It is the only etc., amounted to £205 350 (US $574 980).Excluding school of its kind in West Africa and trains in a the expenditure under the economic programme, the three -and -a- half -year course to a standard a little amount spent for health in the year 1956/57 constituted above that of the Intermediate London City and about 4 per cent. of the total estimated revenue of the Guilds examination. A School for Dental Hygienists Federal Government and amounted to approximately -the first of its kind in West Africa -was approved £4.9 (US $13.72) per head of population of the Federal in 1955 and was expected to open in 1958 upon com- Territory of Lagos.The corresponding figure for pletion of building. the year 1955/56 was approximately £4 (US $11.20). The School of Radiography trains x -ray technicians The health and medical expenditure for the Western for the whole of Nigeria; the course lasts three and a Region, for the year ending 31 March 1957, was half years and accepts 35 students.The School of £1 463 700 (US $4 098 360), amounting to approxi- Medical Laboratory Technology also trains students mately 4.6 shillings (US $0.64) per head of the popula- for the whole country; in 1956 the Institute of Medical tion of the region and about 10 per cent. of the total Laboratory Technology in London approved the estimated revenue of the region.Medical expenditure teaching syllabus and agreed to hold its intermediate in the Eastern Region was 2.6 shillings (US $0.36) examination in Lagos. per head of the population, and 1.5 shillings (US $0.21) There are preliminary training schools for nurses per head in the Northern Region.These figures and midwives at Lagos, at Ibadan (two, one being that do not of course include expenditure by missionary AFRICAN REGION 131 and other non -governmental bodies, which play an In addition, there were 40 leprosy settlements, 13 in important part in the medical services of the Federation. the Northern Region, eight in the Eastern Region, and Hospital facilities available in 1956 are shown in 19 in the Western Region.Most of these are financed the following table. by the regional governments but run by missions.
Government Mission and hospitals private hospitals Total Region number beds number beds number beds
1 Lagos 7 1067 24 292 31 1359 Northern Region . . . . 30 3390 16 797 46 4187 .T Eastern Region 29 1907 38 2258 67 4165 1 Western Region 32 2560 27 1218 59 3778
Southern Cameroons . . . 6 382 13 677 19 1059
Total: 104 9306 118 5242 222 14 548
According to the 1956 annual report of the Federal pilot project (in Western Sokoto), making investiga- Medical Service, among the communicable diseases of tions of sickle -cell trait and chemotherapeutic trials, Africans treated in the clinics and hospitals in Lagos, and preparing plans for a malaria eradication pilot malaria, acute infection of the respiratory system, project in an area of the Eastern Region.The tuber- intestinal helminthiasis, tuberculosis, dysenteries and culosis service of the Federal Medical Service has venereal diseases were commonAccidents, poison- similarly carried out important work in the Lagos ings and violence accounted for some 26 000 hospital area,aswellasliaison work with theregional cases in the Federal Territory of Lagos.In the medical services, each of which has a tuberculosis Western Region, although smallpox was still endemic, medical officer.The tuberculosis mortality rate in no serious epidemics were reported in 1956. A yaws the Lagos Territory was 45.0in1955 and 35.6 control campaign was carried on successfully in Ondo in1956 per 100 000 population.Among 150 000 and Benin provinces by three medical field units.At persons examined with mass miniature x -raysin the end of 1956 there were 70 treatment centres for Lagos in 1955, a rate of five active tuberculosis cases leprosy in the Western Region, with about 7000 per 1000 was found.In the same year a total of patients. 27 000tuberculintestsand8000 BCG vaccina- The Federal Medical Service has an active malaria tions were made inLagos;similarfacilitiesfor service, under the direction of a senior malariologist, tuberculosis control work are made available to the carrying out malaria surveys and a malaria control regions.
PORTUGUESE GUINEA
The Portuguese Province of Guinea lies on the west coast the Portuguese overseas provinces were reorganized. of Africa, between latitudes 10° 59' and 12° 20' north, and is The Central Health Department has technical and made up partly of mainland and partly of islands -the Bijagos archipelago.On land it is bounded by Senegal (French West administrativesupervisionof tendistricthealth Africa) in the north, and by former French Guinea on the east services, 44 health units, the hospitals, aid posts and and south.The total area is about 31 800 square kilometres, pharmaceutical services (to which isattached the with a population of 540 690.The soil is rich and productive. Central Store of Pharmaceutical Supplies), the schools For administrative purposes, the province is divided into councils, and is under the authority of a Governor, who resides of nursing, and the special units for control of leprosy in Bissau, the capital. and other endemic diseases. The activitiesof themedical servicesinclude : protection of the public health by preventive and Health curative measures; control of endemo- epidemic dis- The structure of the health services is based on a eases - intestinalparasiticinfections, treponema- Decree of 1945, under which the health services in toses, bilharziasis, leprosy and tuberculosis; care of 132 FIRST REPORT ON THE WORLD HEALTH SITUATION mothers and children; supervision of the care of Local surveys were made, with assistance from African workers; and the organization of medical care WHO, to determine the prevalence of bilharziasis; for the population through hospitals and aid posts. it was found that prevalence varied considerably Preventive and curative medical services are free to according to the region (from one case among 560 the indigenous population and are provided in hos- persons examined to 12 cases among 250), the average pitals, aid posts, and allother government health rate being 1.8 per cent. establishments. Maternal and child health services have developed The local health units are run by male nurses and considerably, particularly in the more populous areas. visited periodically by the district medical officer. New pre -natal and infant welfare clinics have been The following medical and para- medical personnel set up, and an increasing number of mothers are made up the health services staff in 1956: 20 physicians seeking institutional delivery as a result of their (including six specialists), three pharmacists and eight registration in these clinics during pregnancy and of assistantpharmacists;89 male nurses(including the instruction they receive in pre -natal and post- auxiliaries) and nurses attached to religious orders; natal care. and 25 auxiliary midwives. The province has a training school for nurses, Hospitals and other health establishments under auxiliary nurses and auxiliary midwives.The courses the health services were as follows: two general hos- are of two years' duration, and in 1956 there were pitals, two aid posts, one leprosarium, seven maternity eight students in the regular nursing course, 50 in the centres, one crèche, and 44 health units.There were course for auxiliary nurses, and 15 in the course for also a dispensary for the out -patient treatment of auxiliary midwives. leprosy, and a children's home (with a crèche), both Improvements made in the existing facilities for under private auspices. medical and health care, and extension of their scope, Between 1954 and 1956, no cases of quarantinable are contributing to the reduction of some of the diseases were recorded.Vaccination against smallpox chief endemic diseases.Of particular importance and yellow fever is carried out in almost all districts; in this connexion are the programmes for control in one district alone, 48 176 vaccinations were given of certain specific diseases already mentioned, and during the period under review.Surveys have been the work of the mobile health teams in carrying made or are in progress to determine the prevalence health education campaigns in both urban of the main endemic diseases - tuberculosis, malaria, rural areas.There is a noticeable improvement in filariasis, leprosy, yaws, bilharziasis, communicable the standard of living of some categories of the eyediseasesandankylostomiasis - andcontrol population. programmes are being planned or organized. Progress is being made in housing and urban de- A tuberculosis control centre has been established velopment.There is a marked increase in building in Bissau, through which case -finding surveys and under private initiative, and examples of urbanization BCG vaccination campaigns are being conducted. include two new roads opened in the district of Farim, Between August and December 1956, 2911 tuberculin and the draining of swamps on the outskirts of the tests and 1057 BCG vaccinations were carried out at village.Elsewhere, village markets have been con- this centre. structed, lighting systems and water supplies have been In the course of a yaws campaign in one district, improved (including the boring of wells for potable 1268 cases were found and treated with repository water), and in urban areas septic tanks are being penicillin. installed for the disposal of sewage.
RÉUNION
The Department of Réunion, which is in the southern hemi- the mountain valleys.Two -thirds of the island are so moun- sphere 750 kilometres east of Madagascar, is one of the oldest tainous and barren that very little use can be made of them; the French overseas territories.It is a volcanic island which was population is therefore concentrated in the relatively limited uninhabited until the arrival of a group of French mariners area where cultivation is possible. during the 17th century; it has an area of some 2500 square There are few food resources, the main items of production kilometres, and now has a population of more than 310 000. being sugar -cane, perfume essences, and vanilla.In the past The capital of the island is Saint -Denis. few years, however, efforts have been made to develop food Réunion has a tropical climate tempered by the southern crops and stock -breeding. trade winds and by its altitude.The temperature varies be- The acute population problem in Réunion is aggravated by tween 18° and 20° C in June and 28° and 30° C in December the fact that the present annual excess of births over deaths is on the coast, and falls as low as 5° C at night in June and July in more than 14 000, while food resources, which are inadequate AFRICAN REGION 133
to meet the needs of the population, are only improving very Great emphasis has been laid on hospital construc- slowly.The result is that a large proportion of the people are tion. A modern 450 -bed hospital has been built under -nourished and in poor physical condition. at Saint -Denis; a sanatorium with 200 beds is now Health being built and is due to open early in 1959.Con- struction of a new psychiatric hospital has been decided Since Réunion isa department of France,its upon and is due to begin in 1959.Improvements are administration - including its health organization - still needed in the other hospitals of the department, is identical with that of all metropolitan departments. 1 particularly those of Saint -Pierre and Saint -Paul, Among the communicable diseases,tuberculosis which are the largest towns after Saint -Denis. presents one of the gravest health problems, and In planning improvements needed in the health ser- diphtheria and tetanus are very common.Cases of vices, other matters of urgent priority include the leprosy arestillcomparatively frequent, but this building of more health centres and expansion of disease is not nearly such a serious problem in Réunion the scope of their services; mass vaccination against as it is, for example, in the French departments in smallpox,diphtheria,tetanusand typhoid;and the Caribbean area.Malaria has been practically intensifiedcontrolmeasuresagainsttuberculosis, non -existent in the island for several years. particularly by systematiccase -finding and BCG The infant mortality rate is about 96; this high vaccination. rate is chiefly due to the effect of nutritional diseases, Further development of environmental sanitation intestinal parasitic infections and contagious diseases in the urban areasisalso needed, especially the on a population whichisunder -nourished and, improvement and expansion of existing water -supply consequently, in a deficient physical condition. systems and the construction of new ones. A sewage - disposal system for the town of Saint -Denis is under I See under France, (European Region). construction.
FEDERATION OF RHODESIA AND NYASALAND
The Federation of Rhodesia and Nyasaland covers an area and teacher -training schools, trades and domestic training of 1 262 986 square kilometres, including Lake Nyasa (31 100 establishments, are managed by the missions, local authorities square kilometres).The land is bordered on the south by and by commercial enterprises. A university has now been the Union of South Africa; on the west by Bechuanaland; established in Southern Rhodesia. on the north -west by Angola; on the north by the Belgian The two Rhodesias are served by the Rhodesian Railways, Congo and Tanganyika, and on the east by Mozambique. which connect with the South African Railways at Mafeking. Although the entire Federal area lies within the tropics, most The total length was about 4023 kilometres in 1953.An im- of Southern and Northern Rhodesia is at an altitude ranging portant new line, 644 kilometres long, links the midlands of from 1000 to 1700 metres above sea level.Except for the Southern Rhodesia with Portuguese East Africa.Nyasaland Lake littoral and the Shire valley, the elevation of Nyasaland is served by its own railway system, nearly 805 kilometres long, varies between 800 and 2000 metres.Over a great part of these which connects the country with the port of Beira in Mozam- areas, therefore, climatic conditions are favourable.The prin- bique. cipal rainfall throughout the Federation is limited to a season Main roads connect all the principal centres of the Federation extending from November to March. with one another and with the adjacent territories.The total The population estimate at mid -1956 was 7 281 300. road length is about 85 280 kilometres, of which 17 700 kilo- The Federation is under a Governor -General, and the terri- metres are designated main roads.An airline operates within tories forming it have their own governors. the Federation as well as linking it with important surrounding The most important single food crop is maize.It forms the territories and London.There are international airports at staple diet of a large proportion of the Africans and is also Salisbury and Livingstone. used widely for animal food.Tobacco is the most valuable cash crop in the Federation, and tea comes next.There is a cattle population of some 4.3 million, a high percentage being Health owned by Africans.Large areas of the country are still un- suited for cattle -raising because of the presence of the tsetse fly. The Education Departments of the territories control a number The national public health service of the Federation of schools of various types, but several primary, secondary provides for medical and public health services in all 134 FIRST REPORT ON THE WORLD HEALTH SITUATION areas outside the municipalities.In the larger muni- been started in special districts in Northern Rhodesia cipalities the local authority maintains its own staff and Nyasaland.There has been increased emphasis of medical officers of health, health inspectors and on anti -tuberculosis work in all three regions and health visitors.Itisalso responsible for running special trials are being made with vole bacillus vaccine the infectious disease hospitals with financial assistance in co- operation with copper- mining companies in from the Federal Government.Smaller municipalities Northern Rhodesia.In Southern Rhodesia, where often have their own health inspectors, with a part - the tuberculosis problem is serious, the number of time medical officer of health, or they may rely on the hospital beds fortuberculouspatientshasbeen Federal Government to provide the services.In all increased by facilities and staff provided by the the towns and other centres the Federal Government Federal Government, the local authoritiesand ap- operates directly its own hospitals independently of proved medical missions. the local authority.In 1954 the proportion of the Work has also been proceeding in the campaign total budget allotted to health was 11.3 per cent. against bilharziasis, especially in Southern Rhodesia, The Federal Ministry of Health appoints a Regional through the organization of area control of snail Director of Medical Services in each of the three vectors, and the supply of oral drugs for the mass territories.Each Director has a staff of provincial treatment of African labourers on the farms. medical officers in charge of the provincial areas out- In Southern Rhodesia increased facilities have been side the municipalities.In Southern Rhodesia these provided by the Government in co- operation with medical officers have public health qualifications and local authorities for better hospital care of complicated are separate from the clinical and hospital staffs. They maternity cases.In urban areas this provision is now are responsible for the medical inspection of schools, being used to an increasing extent by African women, control of infectious disease, advice on environmental even for normal confinements.In the two northern sanitation, vaccination and inoculation campaigns, territories the village midwife tradition persists, and and control of food, milk and water supplies.In efforts are therefore made to provide the village mid- Northern Rhodesia and Nyasaland the provincial wives with simple training and equipment.All med- medical officers, in addition to the above -mentioned ical institutions are encouraged to organize maternity duties, also have oversight of the curative and hospital and child health clinics.The school medical service facilities in their areas.All district medical officers has now been incorporated within the provincial health have preventive functions as well as curative work in organization, thus making for wider and more econo- their areas, and health education forms an important mical use of medical staff. part of their duties. A number of pamphlets, films and filmstrips have There were 633 hospitals in the Federation in been prepared for health educational purposes on 1956, including 422 government hospitals, 192 State - nutrition,malaria,bilharziasis,generalsanitation, aided mission hospitals, six local authority hospitals rural water supplies, and leprosy.They are used in and 13 mining and private hospitals.In 1956 also schools, women's clubs and other village meeting - there were 994 registered doctors in the Federation. places.The African broadcasting station at Lusaka In Southern Rhodesia alone there were 2443 nurses, has some programmes on health education, and a 1155 midwives and 304 pharmacists. number of playlets are performed from time to time No facilities exist for medical training, but scholar- in the vernacular languages used in the Federation.In ships are available for medical schools abroad.Euro- the press, health education of the public is restricted to peans can be trained as laboratory assistants at three short cartoon treatment of health problems.Films on centres,leadingtoaqualificationequivalentto health subjects are shown from the mobile units " laboratory technician " in Great Britain.In 1956, touring through the African townships and rural 73 nursing orderlies and 14 health demonstrators areas. passed their examinations in Southern Rhodesia, and The housing situation is at present difficult, largely 14 hospital assistants qualified in Northern Rhodesia. owing to the annual immigration of 15 000 -20 000 Medical aides, health, midwifery, and nursing assist- Europeans.In the urban areas rents form a big ants are trained in Nyasaland, and various other proportion of the family expenditure.During the hospital and nursing auxiliaries are trained in Northern period 1954 -56 a great effort has been made to meet Rhodesia. the shortage of accommodation by the erection of A campaign for malaria control, using residual blocks of flats, and by low -cost, high- density housing insecticides, has been in progress in Southern Rhodesia schemes.African housing has been much improved since 1947, and it now covers the greater part of the by the work of the territorial governments and the area.Pilot projects using the same techniques have local authorities. AFRICAN REGION 135
RUANDA -URUNDI
Ruanda -Urundi is bounded on the north by Uganda, on the hospital care in urban and rural areas, and a public east and south by Tanganyika, and on the west by the Belgian health section in charge of environmental sanitation, Congo.Usumbura isthe capital.The territoryisunited administratively with the Belgian Congo, of which it forms a preventive medicine, medical research laboratories separate Vice -Government General.It has a separate legal and medical education and training status and its own budget.Ruanda -Urundi has a total area The territory is divided into a number of medical of 54 172 square kilometres and is the most densely populated sectors, each provided with a hospital and a network area in Central Africa, with an average of 81 inhabitants per of dispensaries. square kilometre.The total population in 1956 was estimated At the end of 1956, there were at 4 415 595.The indigenous population, representing over 55 hospitals (government, mission and private) and 99 per cent. of the territory's total population, comprises three 135 dispensaries, served by 70 doctors, four dentists, main ethnic groups: the Batwa, the Bahutu and the Batutsi. 39 medical auxiliaries, 80 female nurses and midwives, The Batwa, who are pygmies of relatively unmixed blood, are two x -ray technicians, and five pharmacists.Sixteen assumed to be the earliest inhabitants; they engage primarily in hunting, make pottery and are gradually taking up agriculture. per cent. of the 1956 budget was earmarked for health The Bahutu, negroes of Bantu origin (representing 84 per cent. services.There were 773 qualified indigenous staff, of of the population), are mainly farmers who are beginning whom 93 were medical assistants and 183 were male to take up cattle -breeding; they are healthy and have a high nurses. birth rate.The Batutsi, of Hamitic and Nilotic origin, are remarkable for their size and stature; they are primarily shep- The following students were attending medical herds.There are also other groups, such as, for example, training schools in 1956: 74 as medical assistants, a few thousand Waswahili and Wabwari. 249 as male nurses, 10 as sanitarians, 18 as nurse - The Territory is governed, under a system of indirect adminis- midwives, 57 as assistant midwives, and 64 as male tration, by a Belgian administration headed by a Governor, nursing aides. who also bears the title of Vice -Governor -General.Legislation is normally enacted by the administering authority in Belgium; Important public health achievements in 1956 in- emergency legislation of temporary validity can be adopted cluded: malaria control by residual spraying through- by the Vice -Governor -General and by the Governor - General out the territory (one million dwellings are sprayed of the Belgian Congo.Ruanda -Urundi is divided into two twice a year); a mass campaign against tuberculosis indigenous states, called pays, each of which has a Mwami at its head.Each state is divided into districts administered by by BCG vaccination; leprosy control; improvement chiefs and sub -districts administered by under -chiefs.Councils of the drinking -water supply by the installation of wells have been established at the levels of sub -chiefdoms, chiefdoms, or water -points, which at present serve 2 770 000 in- districts and states, which must be consulted on all matters of habitants; and revaccination of the entire population concern to their areas. against smallpox. The economic activities of the territory are mainly centred around agriculture and stock -raising, with some mining.The In maternal and child welfare, 190 481 consultations principal exports are coffee, ores and metals, livestock, cotton were registered in1956 at 41ante -natalclinics; and hides. 59 896 infants were registered at 61 child -care clinics, The number of schools, both State and privately subsidized, to which 1 356 668 visits were made. for indigenous inhabitants, as well as school attendance, has appreciably increased during recent years, and a third -year Health education of the public is promoted mainly course has been established at the inter -racial boys' school at in the schools and with the help of posters displayed Usumbura.In 1955, 21 Africans from Ruanda -Urundi were at the dispensaries. studying overseas; this number rose to 30 in 1956. A pre - Research work is being conducted on nutritional university institute was opened in 1955 and admitted 21 pupils problems- especially kwashiorkor -at the government during that year. laboratory in Usumbura; the Astrida laboratory is studying rickettsial and virus diseases, tuberculosis, Health salmonella, typhus and shigella in co- operation with The health services of the territory are administered the Antwerp Institute for Tropical Medicine; and the by one senior and one assistant medical officer, and laboratory of the Institute for Scientific Research in auxiliary staff.The health services consist of a medical Central Africa is carrying out a biometric and nutri- assistance section responsible for general medical and tional study (the Rwaza pilot project). 136 FIRST REPORT ON THE WORLD HEALTH SITUATION
ST HELENA AND DEPENDENCIES
The island of St Helena lies in the South Atlantic Ocean, of Control " has been set up for the purpose of 1535 kilometres south of the equator, in latitude 15° 55' south considering the non -statutory control of the training and longitude 5° 42' west.The nearest point of the West African and registration of local hospital nurses.In 1954 continent is 1825 kilometres distant.It is of volcanic origin and contains many rugged mountains, interspersed with ravines. a St Helenian sisterreturnedtotheisland on The south -east trade winds keep the climate cool and equable. appointment,afterqualifyingas State Registered Before the Suez Canal was opened, St Helena was a well -known Nurse and midwife in the United Kingdom.There port of call for ships bound to India from Atlantic ports, and it is a branch of the British Red Cross Society in the was probably used for the refitting of ships.It has an area of 121 square kilometres, and at the census taken in 1956 the popu- island. lation was 4642. A new hospital with 38 beds and modern electrical St Helena is administered by a Governor, who is responsible equipment was completed in 1956.Other hospital to the United Kingdom Government, and is assisted by an facilities in the island include a mental hospital and a Executive and an Advisory Council.All ordinances are made station for leprosy patients (although the latter has by the Governor. The economy depends on agriculture, the principal crops being not been used for many years, since the disease has flax, potatoes and other vegetables.The cultivable area is small. died out).There is a school dental service and five Electricity is available in Jamestown but not elsewhere in the rural health centres.The medical officers and the island, and there are few raw materials; part of the island's food health sister hold various types of clinics at these supply and all other consumer and capital goods are therefore centres and at the out -patient department of the imported.The adverse balance of trade has been aggravated in recent years by a heavy fall in export prices and by rising hospital,includingante -natalandchildwelfare costs.The only industry is the export of phormium tenax as clinics. hemp and tow, and a small amount of rope and twine is also General health is good.The principal causes of manufactured.There are five mills engaged in this process, death are degenerative heart diseases, associated with but only three were in operation in 1958.Special attention is paid to soil conservation and agricultural development, and oldage, and cancer.Roundworm infestationis £82 000 (US $229 600) were allocated from Colonial Develop- common in children in some areas, and in 1958 an ment and Welfare Fund for this purpose for the period 1955 -60. eradication campaign was started by the provision of Of the total area, 2.6 square kilometres are arable, 15.5 square chemical closets in the most badly infected area.The kilometres are suitable for growing permanent crops, 18 are meadow or pasture, and less than 2.5 square kilometres are reputed low incidence of tuberculosis was confirmed wood or forest land. by a WHO consultant, who visited St Helena in 1958 Education is free and compulsory between the ages of 5 and 15. and reported a low immunity to this disease. Practically the whole population is literate. The island is far distant from any other resources Most of the people live in reasonably satisfactory simple rural and from time to time the Medical Department has to conditions.Water supplies are adequate; measures are being taken to prevent pollution and to improve domestic sanitation deal with serious cases of illness on ships that call at in rural areas.Assistance is provided by the Government to the island, including major surgery. enable people to build their own homes, to extend existing ones, and to effect repairs.
Ascension Health The Public Health Department is administered by The island lies some 1100 kilometres north -west of a Senior Medical Officer advised by a Board of Health. St Helena in latitude 8° south and longitude 14° west, Of the total 1958 budget, 11.6 per cent. was devoted to and was made a dependency of St Helena in 1922. expenditure on health.Health personnel in the same It has an area of 83 square kilometres, and its rough year consisted of two registered physicians, one dentist, basaltic hills reach nearly 900 metres above sea level. three nursing sisters, eight nurses, three orderlies, and The climate is kept cool by the south -east trade winds. two sanitary and health auxiliaries. Provision is made There is little vegetation apart from a small area on for a health sister, but the post was vacant in 1958. Green Mountain, on which there is a farm which Most of the medical and nursing staff are trained provides the inhabitants with food.The local supplies overseas.Sanitaryassistantsaretrained by the are supplemented by imported food.The population sanitary inspector, and a scheme was started in 1954 at the end of 1957 was 434, most of whom are em- for training midwives for work in rural areas. A semi- ployed by Cable and Wireless Ltd.The principal official body called the " Midwives and Nurses Board settlement is Georgetown. AFRICAN REGION 137
Ascension is administered by the Government of It has an area of about 100 square kilometres, and at St Helena, through the local manager of Cable & Wire- the end of 1957 the estimated population was 290. lessLtd., who has magisterial powers.Another The island is in the charge of an Administrator officer of the Company is appointed a Justice of the appointed by the Governor of St Helena, assisted by Peace.There are two St Helenian police constables. an Island Council. Cable & Wireless Ltd. maintain radio and telecom- After whaling and sealing died out at the end of the munications between Africa and South America. last century, the island remained almost isolated until Since November 1955 there has been a radio -telephone 1949, when a South African fishing company was service to the United Kingdom. granted a concession to establish a fishing industry A medical officer, employed by Cable & Wireless there.There is now a substantial export of tinned Ltd., is responsible for the health of the population. and frozen craw -fish.Since1952 the island has gained some revenue from the sale of postage stamps. Tristan da Cunha Living conditions have improved with the rise in prosperity and the advent of an agriculturalist, who is Tristan da Cunha, a dependency of St Helena maintained by the fishing company.Connexion with since 1938, is one of a group of islands in the South South Africa is provided by the company's vessels. Atlantic Ocean about 2400 kilometres south -west of The fishing company employs a doctor and a St Helena, in longitude 13° west and latitude 38° south. qualified nurse to look after the health of the in- Tristan is a volcanic peak, rising to over 200 metres habitants, and also provides a qualified teacher for above sea level.The climate ranges from cool to cold. educational purposes.
SAO TOME AND PRINCIPE
The Portuguese Province of São Tomé and Principe consists The sum earmarked for health services represented of the two islands of São Tomé and Principe and some smaller 8.37 per cent. of the total government budget in 1954 islands, lying in the Gulf of Guinea in the Atlantic Ocean, with a total land area of 964 square kilometres, of which Sao Tomé and 7.49 per cent. in 1956.These occupies 854.The islands are of volcanic origin. exclusively to the amounts set aside for running the The estimated population in 1955 was 61 882.The island services;costs of construction and equipment of and city of São Tomé is the capital and the seat of the Governor. hospitals and other establishments are met from For administrative purposes, the province is divided into councils under the charge of an administrator. another fund. The soil is fertile, and coffee, cocoa, palm oil, groundnuts and One of the most important public health achieve- copra are produced. ments has been the tuberculosis control campaign. In 1952, a tuberculosis control centre was set up, Health together with a case -finding and BCG vaccination service, and a mass campaign was started, which The health services are organized on the basis of included x -ray examination, tuberculin- testing, and a Decree of 1945 relating to the reorganization of BCG vaccination. A new ward for the in- patient health services in the Portuguese overseas provinces. treatment of tuberculosis patients was established at A central Health Department directs and supervises the Central Hospital in 1955. two district health services - one in each island -, Encouraging results have been obtained in the ten health units, the Central Hospital in Sáo Tomé, control of malaria by means of house -spraying with the Regional Hospital in Principe, a tuberculosis residual insecticides, and treatment of swamps with dispensary, and a nursing home.Some agricultural malariol. undertakings run private hospitals and dispensaries The tsetse fly, which was eradicated from the island for the medical examination and care of their workers. of Principe in 1911, was again found to be present In 1956, there were 60 private hospitals and other in 1956, and a special service was established to take health establishments.Medical care of workers is immediate control measures. provided free in the government hospitals and other The government health personnel impart health health establishments. education to the people, to help them to raise their In 1956, the staff of the health services was as standard of hygiene and improve their nutritional follows: 13 physicians, 208 male nurses, six midwives habits,thereby defending themselvesagainstthe and seven pharmacists. prevalent endemic diseases. 138 FIRST REPORT ON THE WORLD HEALTH SITUATION
There is a school for auxiliary male nurses, with a These plans include the construction of roads, water training course of two years. supplies and sewage -disposal systems, the installation Plans are being concluded for the urban development of electricity, the building of schools, public utilities, of the populated localities of Taindade, Guadalupe, health units, shopping centres, and houses for govern- Neves, Madalena, Sao Joao dos Angolares, Bombom, ment officials.Work is to begin in 1958 in the first Santo Amaro, Santo António do Principe and Santana. five of the localities.
SEYCHELLES
The Seychelles are a group of 92 islands in the Indian Ocean, medical officers.Compilation of vitalstatisticsis with a total area of 405 square kilometres.The climate, in undertaken by the medical officer of health from spite of the latitude (4° south of the equator) is equable and the islands are healthy.The estimated population in 1956 was data provided by the chief civil status officer.The 40 417, of whom 10 000 lived in Victoria -the only town- followingrateswererecordedfor1956:birth situated on the principal island of Mahé.The rest of the rate,36.9; death rate11.5; and infant mortality population is distributed over the rural areas, with slight aggrega- rate, 54.2. tion at the 14 different parish headquarters.Over a thousand Medical care is provided in one general hospital plantation labourers and their families live in the outlying island groups, of which there are 55, at distances from Mahé varying with 126 beds, three cottage hospitals with a total of from 97 to 965 kilometres. 55 beds, one dispensary with two beds and two out- The economy is almost exclusively dependent on agricultural patient dispensaries.There is, in addition, a mental exports, copra and essential oils.Coco -nut plantations are hospital and a leprosarium, and a tuberculosis sana- estimated at 29 000 acres (11 735 hectares), cinnamon planta- tions at 12 000 acres (4856 hectares), and there is grazing land in torium has recently been completed. most areas. Apart from the staff of the Medical Services men- Primary education is free.In 1954 about 75 per cent. of the tioned above, there were the following medical and child population were enrolled in primary schools.For those health personnel in the territory in 1956: five doctors ; who complete the primary course satisfactorily, free education one dentist; four nursing sisters (religious); one sister for another three years is available.Vocational training is given in a technical training centre.Training in domestic tutor;16 nurses qualified in general nursing and science is provided at the two government modern schools and midwifery; two qualified male nurses; 17 probationer at the girls' secondary school. general nurses; three probationer male nurses, seven probationer midwives;onelocallytrainedphar- Health macist. A venereal disease control campaign was carried out The Medical Services are under a Director, whose between 1953 and 1956, and as a result syphilis is staff includes a Senior Medical Officer of Health, a reported to have been eradicated, although gonorrhoea public health educator, a senior health inspector, still remains.So far no malaria and trachoma cases 10 assistant health inspectors and six public health have been reported. A programme of immunization nurses. A separate medical officer of health has been against diphtheria, whooping -cough and tetanus was designated to take charge of public health, and the started in 1956.Rigid quarantine precautions exist principal islands have been divided into" health against the infectious diseases, vaccination against districts ".It is hoped eventually to have a health smallpox and yellow fever being required from inspector and a public health nurse stationed in travellers. each district. A school health service has been established and it The proportion of the government budget allocated is hoped to cover all schools in the principal islands to public health was 19.5 per cent. in 1956 -2.5 of the territory.Infant welfare clinics have been per cent. being for administrative and public health set up in rural areas, and it is planned to have one servicesand17.0percent.formedicalcare, clinic in each health district. representing a total per capita cost of 17.64 rupees With the object of improving environmental sanita- (US $3.70). tion, a programme was initiated with assistance from So far as vital statistics are concerned, all births WHO in August 1953.This included a morbidity and deaths are registered; all deaths, except a very survey to investigate epidemiological factors and the few ocurring on outlying islands, are also certified by incidence of intestinal diseases. AFRICAN REGION 139
SIERRA LEONE
Sierra Leone lies on the west coast of Africa, bounded by certified.Records of disease and death in the govern- former French Guinea on the north and by Liberia on the east ment hospitals, however, indicate the most important and south -east.The country is well watered and hilly, and the greater part is a plateau between 300 and 1000 metres above causes of morbidity and mortality.Infant mortality sea level.The climate is hot and moist, with an annual rainfall in Freetown in 1956 was 133, but no doubt the figure of more than 380 centimetres, the rainy period being between in the provinces is much higher. July and September.The capital is Freetown, one of the finest There were in 1956 a total of 22 hospitals, with harbours in West Africa.The population estimate for 1956 936 beds and 117 cots.In addition, 42 health centres was about two million, with 70 000 in Freetown, but there are no exact figures. and dispensaries were distributed throughout the The chief agricultural products are palm kernels and palm oil, territory.Four of the five new provincial hospitals and the main food crop is rice.Forestry is being developed, which were under construction have now been almost and diamonds are found in the territory. completed, but on account of staff shortage in the Public Works Department only two have been opened. Health A number of existing units are being extended, especially to provide additional services for the care Since 1953 the Minister for Health, Agriculture, and of mothers and children.The last two of the 20 health Forests has been responsible for health policy.The centres built under the Colonial Development and healthservicesareadministered by the Medical Welfare Scheme were completed in 1956; unfortun- Director and his colleagues in the Health Department. ately, owing to lack of staff, it was only possible to On the whole, local government authorities are taking bring nine of these centres into use.The temporary an increasing interest in the health services, but the tuberculosis hospital at Lakka (about 16 kilometres administration of localservices,suchashealth from Freetown) did good work during the period centres, dispensaries, and environmental sanitation, under review, but still awaits reconstruction and new was handed over to the District Councils in 1954, equipment.The infectious diseases hospital at Lakka and staff was assigned or transferred from the Medical was not finished by the end of 1956, and alternative Department for the purpose.Owing to problems accommodation had to be found to serve the needs of of taxation and other difficulties, however, it has been the smallpox patients in a unit generally used as an decided that health centres and dispensaries should annex to the Connaught Hospital in Freetown.In revert to the Medical Department in 1957, although consequence of the interruption there was a list of over the sanitary staff would still be assigned to the District 2000 patients awaiting operation at the end of the Councils.At present the Health Department admi- year.Overcrowding in the Kissy mental hospital nistersthehospitalservices,healthcentres and continues to increase, as in mental hospitals in most dispensaries, and is responsible for the control of countries, and at the end of 1956 there were over epidemic disease, port sanitation and control of the 200 patients in accommodation intended for110. quarantine group, and medical stores. Every effort is being made to develop home care of The staff of the medical and health services in 1956 the mentally sick. included some 46 medical officers, 276 nurses and The principal diseases notified during 1956 included midwives, six dental officers, 21 radiographers and dysentery (2709 cases with four deaths), pneumonia laboratory personnel, 72 pharmaceutical personnel (1023 cases with 17 deaths), and smallpox (946 cases and 79 other staff.Of the medical officers on the with 19 deaths).As a result of the outbreak of staff of the Medical Department,19 were Sierra smallpox, the port and airport of Freetown were Leoneans. declared infected under the International Regulations Expenditure on medical and health services amoun- and remained so from August till the end of the ted to £456 097 (US $1 277 225) in 1954, and £564 887 year.Altogether, 612 880 persons were vaccinated (US $1 581 873) in 1956; this does not include expendi- against smallpox during 1956, 6924 of them in and ture on medical schemes under development plans, around the airport as a special preventive measure. which by the end of 1956 amounted to £87 616 There were no cases of yellow fever during 1956, (US $245 354). but 2293 persons were vaccinated against this disease. It is not possible to present accurate and up -to -date Malaria is endemic in Sierra Leone, and control vital and health statistics for Sierra Leone, because measures include the protection of Freetown by only a very small proportion of the deaths are medically application of larvicides, supplemented by residual 140 FIRST REPORT ON THE WORLD HEALTH SITUATION spraying in the urban and rural districts of the town, at the school clinic has been so heavy that the clinic and around the airport.Regular estimates of the may be said to have become in effect a children's Aëdes index are made in the neighbourhood of the out -patientdepartmentof themain Connaught port and of the airport. Hospital, and the medical officer in charge has been A mobile endemic diseases control unit was formed unable fully to carry out the normal duties of school during 1956 as part of a yaws control campaign in inspection.More than31 000attendanceswere which UNICEF and WHO are assisting. A mass recorded at the clinic in 1956.Treatment is often treatment campaign was carried out during the year made difficult by the fact that many young children in a pilot area, where 230 470 people (including 92 366 between the ages of five and ten visit the clinic children) were examined and treated; the total number unaccompaniedbyadultsandareunableto of active yaws cases found was 50 560, although describe their symptoms accurately; they cannot be this figure should be interpreted with caution.Apart expected to understand the treatment instructions from individual variation in the diagnosis of yaws, given them, nor can they be entrusted with medi- persons diagnosed as suffering from other diseases, cines.Outside Freetown there is no special school such as tropical ulcer, may also have been treated and medical service,but schools rely upon local hos- included in the number of cases.This mobile field pitals and medical officers.A routine weekly visit unit brought medical services to many villages for the by the school medical officer has, however, been first time and received an enthusiastic response from instituted at one of the new health centres, where the population; furthermore, valuable experience was it was found that many children were coming for gained by the members of the teams, and it is believed treatment. that such units will play an important part in bringing There is no medical school in the territory; during modern medical treatment - beyond the scope of 1956 four Sierra Leonean doctors were undergoing the yaws control campaign - to the people living post -graduate training abroad.Nurses and auxiliary in the bush, who make up a large proportion of the staff are trained locally. A Nurses Ordinance, es- population. tablishing a Nurses Board and a register of nurses Progress in tuberculosis control has been made as and nursing assistants, was enacted during 1956 a result of surveys carried out with the assistance with the object of raising the standard of nursing of WHO. A leprosy control programme isalso throughout the territory, and a Midwives Ordinance being planned. for registering and enrolling midwives and village As regards the maternal and child health services, maternity assistants with a similar object was also there has been a steady increase of maternity cases enacted.NursesaretrainedattheConnaught admitted to the provincial hospitals, and the use Hospital in Freetown, and at Bo Hospital in the Pro- and training of village maternity assistants have on the tectorate. A nurses' hostel is under construction at whole been satisfactory, although the facilities for Bo to accommodate female nursing students.Mid- maternity work are inadequate in many hospitals. wives are trained at the Maternity Hospital in Free- In 1956, 53 girls successfully completed the course town.Dispensers are trainedatthe Connaught and were supplied with UNICEF midwifery kits Hospital, and health inspectors in a school at Bo, for their work.There is an urgent need to build where 36 students were enrolled in 1956; one of the maternity centres which are already planned for these students passed the examination of the Royal all hospitals.In Freetown, 57 per cent. of the births Institute of Health (West Africa). registered in 1956 took place in the maternity hospital In each province the Medical Department is build- (a record number of over 2000), and attendances at ing up teams, under a chief health superintendent, the ante -natal, post -natal, and infant welfare clinics to organize sanitation and town planning.Sanitation amounted to over 45 000.The domiciliary mid- in rural areas is generally primitive, and great diffi- wifery service in Freetown has been in operation culties have arisen in recent years on account of the since 1954; owing to shortage of midwives progress lucrative development of alluvial diamond mining has been slow, but gradual advances are recorded. in some areas, with its attendant overcrowding, shack A school medical service has been in existence in building, shortage of water, lack of latrines, and risk Freetown for many years, but recently attendance of imported infectious diseases. AFRICAN REGION 141
SWAZILAND
Swaziland is bordered on the north, west and south by the Trans- meeting of the Swazi National Council with the vaal province of the Union of South Africa, and on the east by Resident Commissioner. part of the Natal province and Portuguese East Africa.It forms three fairly well defined regions running north and south, descen- Curative services are provided at eight hospitals ding from about 1500 metres in the west to 150 metres in the east, (four controlled by the Government, three by missions, known as the high, middle and low veld.It is a well -watered and one by a mine), with a total of 503 beds, and 22 subtropical country with considerable areas of good soil that dispensaries.Government medical officers are posted could be good agricultural land under irrigation.The rainfall is irregular.The territory has an area of about 17 364 square to hospitals for general work and also supervise dis- kilometres and at the 1956 census the population consisted of pensaries as part of their duties.The headquarters 229 744 Africans, 1378 of mixed origin, and 5919 of European of the Medical Department is at Mbabane, where the origin.The Swazis are of Bantu race, akin to the Zulu.They main government hospitalislocated.Ante -natal are an agricultural and pastoral people, living in small family and maternityservicesare providedatgovern- kraals. The territory is governed by a Resident Commissioner under ment and missionhospitals and atdispensaries. the direction of the High Commissioner for Basutoland, the There is routine inspection of schoolchildren at some Bechuanaland Protectorate and Swaziland.For administrative schools. purposes, the territory is divided into six districts, each in charge The Medical Officer of Health isstationed at of a District Commissioner.The traditional system of govern- ment among the Swazi people is a Paramount Chief acting in Bremersdorp, where there is a public health laboratory. conjunction with the Council, normally composed of the chiefs In addition to the Director, the staff of the Medical and leading men. The Paramount Chief and his Council have Department consists of one medical officer of health, been formally recognized as the Native Authority for the seven medical officers, two pharmacist- storekeepers, territory and have power to issue to Africans in Swaziland two matrons, 14 nursing sisters, two health inspectors, legally enforceable orders on a wide range of subjects.Native courts and a Swazi National Treasury have been set up.There one laboratory technician, three hospital assistants, are four proclaimed townships, each with an Urban Area two dispensers, two pupil dispensers, 70 nurses, two Advisory Committee. out -patientattendants,two laboratoryassistants, The Swazis are essentially a pastoral people in transition to 10 ward attendants, 14 orderlies, one senior malaria agriculture and largely content with subsistence farming.There are no manufacturing industries of any significance.The mining assistant, and 10 malaria assistants. industry is an important feature of the territory's economy, and Estimatedterritorialexpenditurefor 1957/58 mining royalties and income tax from mining concerns ensure the amounted to £1 222 670 (US $3 423 476), of which balancing of the budget without grants -in -aid.Livestock pro- the allocation for the Medical Department was 10.2 duction is increasing in importance and more crops are grown per cent. for export, although the territory is not yet self -supporting in food.Spectacular developments have taken place in recent There is no medical school in the Protectorate. years in commercial forestry and irrigation, in which both the African nurses and midwives are trained at the Raleigh - Colonial Development authorities and private enterprise have Fitkin Memorial Hospital, which is recognized by taken important parts.In 1957, more than 164 000 acres the High Commission Territories Nursing Council (66 000 hectares) had been afforested. The chief imports are general merchandise, building materials, for the issue of certificates in general nursing and motor vehicles, petrol, oil, etc., mining stores and groceries. midwifery.There are two courses of training, one The chief exports are asbestos, slaughter stock, fruit (fresh and for the High Commission Territories Nursing Council canned), seed cotton, butter, rice and patulite. A sugar industry Certificate and the other for the Swaziland Executive has now been established. Nursing Committee's certificate.The length of the Education is not compulsory for African schoolchildren, but their enrolment in schools has increased by 241 per cent. in the courses is four and a half years -about three years in past ten years, to 26 624. nursing and 18 months in midwifery.There is also a two -year course for nursing aides.In 1957 there were 40 probationer nurses in training. African dispensers and laboratory assistants are Health trained at two of the Government hospitals, and African malaria assistants at the public health labora- The Director of Medical Services is responsible tory as required. for the administration of the government Medical There is one leprosy hospital, one malaria control Service; he is, ex officio, a member of the Protectorate unit and a public health laboratory for research on European Advisory Council and attends the annual malaria and bilharziasis.The more complicated 142 FIRST REPORT ON THE WORLD HEALTH SITUATION pathological and bacteriological examinationsare scheme of tuberculosis control is under consideration. carried out at the South African Institute for Medical Investigational work into the problems of bilharziasis Research in Johannesburg. is being continued. The important health problems in Swaziland are Water supplies, outside the urban areas, are assured tuberculosis, malaria and bilharziasis.Considerable by wells and rivers but are subject to pollution at success has been achieved in malaria control. A the onset of the rains.
TANGANYIKA
Tanganyika is in East Africa, and extends from the Umba sentatives of religious, cultural, educational and social service River on the north to the Rovuma River on the south, with a organizations, with the aim of co- ordinating and extending coastline of about 724 kilometres; it includes the adjacent islands, social work in the country.The Tanganyika Council of Women except Zanzibar and Pemba.The total area is 939 361 square has established a number of African women's clubs and does kilometres including about 51 780 square kilometres of water. much to encourage African participation in homecraft and Dar -es- Salaam is the capital and chief port.The estimated cultural classes. population at 31 December 1956 was: Africans,8 390 000; Europeans, 25 000; non -Africans (mainly Asians), 106 000.The African population is made up of members of more than Health 100 tribes, each with a distinctive dialect and varying customs. Most of the tribes are of Bantu origin, although there are con- siderable Hamitic and Nilo- Hamitic intrusions.Swahiliis The Medical Department, under the responsibility generally spoken and understood. of the Minister of Social Services, is in the charge of The territoryisdivided for administrative purposes into the Director of Medical Services, with headquarters eight provinces.Native administrations have been established at Dar -es- Salaam.It is responsible for formulating formally throughout the rural areas, and the responsibilities, rights and powers of Native Authorities have been defined. medical policy, for the control and treatment of Revenues are vested in Native Treasuries or Local Council infectious diseases, the administration of government, Treasuries.Dar -es- Salaam and Tanga operatetheir own provincial and district hospitals, the training of local services, and there are five other urban authorities as well as personnel, and the supervision of local health services. 25 township authorities. There is a senior medical officer in each of the eight The economy of the country is based mainly on the production and export of primary produce, chiefly sisal, coffee, cotton, hides provinces, and district medical officers are appointed and skins, and on the growing of staple foodstuffs (maize, to local areas for public health work. sorghum, cassava, millet, fruit, vegetables and sweet potatoes In 1956, the establishment of the Medical Depart- forlocalconsumption).The most important commodity ment consisted, in addition to the Director, of one exported issisal, of which 176 500 tons were produced in 1955 -approximately one -half of the world's supply.There is Deputy Director, three Assistant Directors, 12 spe- an important mining industry, the main exports being diamonds, cialists, 11 senior medical officers, 75 medical officers, gold, lead and mica.The estimated value of mineral production one matron -in- chief,ninematrons,137nursing in 1956 was £5.5 million (US $15 400 000).There is also an sisters, 33 health inspectors, three laboratory techni- important trade in mill-sawn timber.Investigation of oil - cians, and three radiographers.Other staff included bearing possibilities is being carried out in the coastal belt and adjacent islands. A branch of the United Kingdom Atomic 10 medical officers (East African), 55 assistant and Energy Authority is now established in Tanganyika, and sub -assistant surgeons, 375 trained nurses and mid- intensive prospecting with scintillometer and geophysical equip- wives, 185 medical assistants, 47 laboratory assistants, ment is being conducted. A number of successful new fisheries 45 assistant health inspectors, and five radiographer have been established on the larger dams, and much coastal assistants. fishingiscarriedout,almostexclusivelyby indigenous inhabitants. Medical expenditure for 1956/57 amounted to 12.4 Primary schools for all races are maintained by the Govern- per cent. of the total budget. ment, voluntary agencies and local authorities.Secondary In 1956 there were 53 government general and education for the African and Asian communities is provided at special hospitals (tuberculosis, infectious and mental), government and grant -aided schools.Facilitiesfor higher education are offered by the University College of Makerere at with a total of 5484 beds, and 20 government dis- Kampala (Uganda) where, in 1956, there were 167 students, pensaries, with 402 beds.Mission hospitals and including five women, from Tanganyika. dispensaries number 212, with 5441 beds, and there Community development is the responsibility of the Depart- are 565 Native Authority dispensaries with a total ment of Social Development.As regards welfare, there is a traditional tribal system of social security for the individual. of 729 beds.There were inall 947 out -patient A Tanganyika Council of Social Service was established in 1956, dispensaries, 227 maternity centres and maternal and consisting of a number of government nominees and repre- child welfare centres, eight tuberculosis units (519 AFRICAN REGION 143 beds) and 18 leprosaria.Out -patient treatment was Poliomyelitishasincreasedduringtheperiod given to 18 472 leprosy patients. 1954 -56.Proposals have been made for a survey During the period 1954 -56 emphasis was placed of the incidence of the disease in certain parts of the on the expansion of training facilities, with a view territory with a view to deciding on the practicability to providing the trained staff necessary for the planned of control by selective vaccination or other means. development of curative and preventive health services. Preventive measures have been successful in checking Training of various types is carried out at 26 govern- the spread of plague.Filariasis has been under ment and mission hospitals.The first trained health investigation for some years by the East Africa nurses entered the Service in January 1954 and the Institute of Research, and much progress has been first government- trained assistant health inspectors made in epidemiology and control. took up posts in January 1955.Government training Respiratory diseases and diseases of the digestive of village midwives started in 1956.A Nurses and organs are the main causes of morbidity, while Midwives Council established in 1952 is responsible tropical ulcer and anaemia are not uncommon for the conduct of training of nurses and midwives, Maternal and child health services are expanding. and the Tanganyika Medical Training Board controls District hospitals have maternity and child welfare thetrainingof medical,laboratory,dental and clinics, and health visitorsalso conduct them at pharmaceutical assistants, all of whom follow a three - dispensaries.In some places a domiciliary service year course.The total number of trainees in govern- has been introduced with good results. ment and mission training centres at the end of 1956 A health education section of the Medical Depart- was 938, exclusive of village midwives. ment was established in 1956, and a workshop was Malaria is an important public health problem in set up for the production of visual aids and other most parts of the country, with a varying degree of materials required for educative work.Simple and endemicity. A Malaria Unit (part of the Medical practical health education is demonstrated through Department)isresponsible for control measures. the medium of women's clubs by the Social Develop- Residual spraying has been carried out in some ment Department, and the press and radio are widely important urban areas, townships and minor settle- used for the purpose. ments.In1956spraying of peri -urban swamps The Council for Medical Research for East Africa, around Dar -es- Salaam with dieldrin granules was of which mention has already been made in the carried out. A long -term investigation on malaria is review of Kenya (page 120), has two of its four main being conducted in the Pare /Taveta area. institutions in Tanganyika: the East African Institute Exact information about the incidence of tuber- of Malaria and Vector -Borne Diseases at Amani, culosis is lacking, but the disease appears to be on and the Medical Research Division at Mwanza.The the increase in some areas. A survey made among former conducts research into malaria, bilharziasis the Masai tribe showed a fairly high infection rate. and other diseases, and provides advisory services Although fullcontrol measures are not applied throughout Africa; the latter carries out work on throughout thewholeterritory,a province -wide various problems, including the biochemistry, etc., control scheme has been started in the Southern of nutrition, filariasis, haematology and bilharziasis. Province with the appointment of a full-time govern- In Tanganyika much medical research is also under- ment tuberculosis officer and the co- operation of taken by individual workers in varioussubjects, mission hospitals. such as bilharziasis.The Medical Department Mal- Bilharziasis is the cause of some concern, parti- aria Unit carries out research into malaria and related cularly because of the risk of its spreading concur- problems.Other departmental research is concerned rently with the development of irrigation and static with drug treatment in trypanosomiasis and yaws. water schemes.The disease iswidespread but is A Public Health (Sewage and Drainage) Ordinance mainly prevalent in the warmer areas around Lake was passed in 1953.In the central area of Dar-es - Victoria and on the coast. Salaam and Tanga there is a water -borne sanitary There were 646 cases of trypanosomiasis in 1956, system for excreta disposal, and storm -water drainage the least recorded since1952.Control measures is in process of being installed in Dar -es- Salaam. are the responsibility of inter -territorial as well as Elsewhere in urban areas excreta are disposed of by territorial organizations. septic tank, cesspit or bucket latrine systems.Pit The prevalence of yaws varies and is highest in the latrines arestillthe principal disposal system in Western Province. A number of limited treatment African urbanareasand inruralareas,where campaigns with penicillin have been undertaken in theconstructionof bore -holelatrinesisbeing recent years. encouraged. 144 FIRST REPORT ON THE WORLD HEALTH SITUATION
AUTONOMOUS REPUBLIC OF TOGO
Togoland is a narrow strip of land extending almost due north ward to a dispensary with some in- patient accommoda- from the Gulf of Guinea.It covers an area of about 55 000 tion or a simple rural dispensary; these units, accord- square kilometres and averages 600 kilometres in length and ing to the services they offer, are staffed by an African 120 kilometres in width.It is bounded on the west by Ghana and on the north and east by the French West African territories physician, a health assistant or a competent male of Haute -Volta and Dahomey respectively.The climate is nurse. mainly tropical, with a rainy season from July to September. There is a central hospital at Lomé, opened in 1954, The population at the end of 1955 was estimated at 1 094 000 which has 44 wards and 480 beds (including the mater- Africans and 1300 Europeans.The capital is Lomé. The ethnic composition of the population is extremely com- nity unit) and which affords services in most of the plex, and tribal and cultural ties tend to reach east and west modern specialties, all under the charge of qualified across the frontiers into neighbouring territories rather than doctors.This hospital deals with all complicated from north to south.The central chain of hills which in the and serious cases which are beyond the competence past constituted a natural obstacle to migratory movements services. divides the territory roughly into two distinct ethnic sections. of thedistrictmedical Other medical The northern section is populated mainly by tribes of Sudanic facilities are provided by 10 auxiliary hospitals or origin, while those of the negroid type are predominant in the medical centres with a total of 1046 beds, 115 dis- south. pensaries (54 beds), and six privately -run rural dis- Maize, millet, yams, cassava, groundnuts and other crops pensaries. A further 370 beds are provided in 14 are cultivated by the Africans; oil palms and dye -woods grow in the forests, but the main commerce is the barter trade for separate maternity units.There are also two leprosy palm oil, cocoa, rubber and copra carried on with the European treatment centres, with a total of 710 beds, and three factories.Indigenousindustriesincludeweaving,pottery, treatmentcentresfortrypanosomiasis(72beds) smithwork, straw plaiting and wood carving. A Mines Depart- attached to medical centres.There is no special ment was set up in 1953 after the discovery of valuable deposits of phosphates, chromite, iron and bauxite. mental hospital, with the exception of a small 12 -bed unit at Zébé, which is used for the observation of mental cases.In 1956, a total of 1 478 571 persons, mostly Health Africans, received medical care at out -patient depart- The health services of Togoland are under the res- ments of hospitals, medical centres and dispensaries; ponsibility of the Minister of Public Health and are a further 26 283 were treated as in- patients. divided, at both the central and the local level, into The staff of the health services in 1956 was as Medical Care Services and Mobile Health Services. follows : At the central level, the Director of Public Health is Physicians, graduates of French medical schools 20 immediately responsible to the Minister and isin Physicians, graduates of the Dakar Medical School12 charge of all the services, assisted by an administrator Pharmacists, graduated in France 1 and by a chief pharmacist, who is in charge of the Pharmacists, graduated at Dakar 1 central pharmaceutical supply service, the chemical Administrators 1 Dentists, trained in France 1 laboratory, and supervision of pharmacies throughout Midwives, trained in France 2 the territory.Advice on matters of health policy is Midwives, trained at Dakar 29 given by a Higher Public Health Council, whose Male nurses, French diploma 2 chairman isthe Minister, the Director of Public Male nurses, local diploma 242 Health being technical adviser to the Minister and Female nurses, French diploma 11 Female nurses, local diploma 47 vice -chairman of the Council. Health assistants 32 At the local level there are 11 health districts corres- Sanitarians 34 ponding to the territory's administrativedistricts, Other auxiliary technical staff 89 each under the charge of a medical officer, who is at the same time physician in charge of all health Twenty -nine members of the above staff were Euro- establishments in the district.In the chief town of pean and 495 were African.In addition to the staff each district there is a medical centre, consisting at employed in the health services, there were four least of a polyclinic, a maternity clinic, and general privatepractitioners,of whom two had French in- patient accommodation, including a surgical ward degrees and two had graduated from the Medical and an operating- theatre.At other central points School at Dakar; six pharmacists with French dip- throughoutthedistrictthereareestablishments lomas, and two midwives, one with a French diploma, varying in size from a polyclinic with a maternity the other with a Dakar diploma.There are no other AFRICAN REGION 145
medical or para- medical staff in the country in public than 4 per cent., but further consolidation measures or other employment. are being planned before yaws control can be left in Control of communicable diseases is carried out the hands of the dispensaries, which are adequately by the Mobile Health and Preventive Services, whose equipped to deal with the low rate of incidence that activities cover more than half the northern portion itis hoped willresult from the campaign.On of the territory, and who have their own mobile teams, completion of the yaws control programme, mass equipment and transport for case -finding surveys campaigns are planned first against leprosy and then and curative and preventive care of the rural popula- against tuberculosis. tion.These teams carry out systematic vaccination Ante- and post -natal care is afforded at all the campaigns against smallpox and yellow fever; take maternity and obstetrical units attached to the medical measures against trypanosomiasis in areas where this centres and dispensaries, and a special home visiting disease is endemic; detect cases of leprosy and send service has been organized at Lomé.In 1956, 6016 patients to leprosy treatment centres; and also provide deliveries took place in hospital and 1093 deliveries simple medical servicesin remote areas,sending were assisted by health staff in the home.In all, patients who need further treatment to the nearest 14 444 pregnant women received ante -natal care, and dispensary centre.In view of the very valuable 4805 received post -natal care; 72 481 infants under services offered by these teams, it would be most one year of age and 109 622 children between one and desirable, if circumstances permitted, for many more four years of age were also seen at infant and child teams to be formed, in order to give a better coverage welfare clinics. of the areas in which they operate. Physicians,pharmacists,dentistsand midwives Large -scale control campaigns are at present being are required to hold French State degrees or diplomas carried out, with assistance from WHO and UNICEF, or a recognized equivalent, such as the diploma of againstmalaria and yaws.The malariacontrol the Medical School at Dakar. A scholarship sys- programme, which started in1953, had covered tem enables qualified African students to complete 3000 square kilometres by 1956 and protected 360 000 their studies in France.Thus, in 1956, the following inhabitants.Since the beginning of the campaign Togolese were studying in France: 14 in medicine, the Anopheles index had dropped from 80 to 7 per two in dental surgery, six in pharmacy, five in mid- cent. by 1956, and the spleen rate from as much as wiferyandtwo innursing. In Togo training 65 to between 6 and 9 per cent.Further chemo- courses are organized for health assistants (to hold prophylaxis campaigns were planned for1958 in posts of importance, such as that of head of a dispen- two pilot areas, to be extended if successful to other sary), for male and female nurses (a two -year course parts of the territory.The mass yaws control pro- at the nursing school attached to Lomé Hospital), and gramme started in 1956 and in its first phase covered for sanitarians (a one -year course under the auspices 570 000 persons, of whom 78 900 active yaws cases of the Lomé Public Health Service).Some nursing and 172 978 contacts were treated.The firstre- students go to schools in Ayos (French Cameroons) or survey showed a decline in yaws morbidity from its Brazzaville (French Equatorial Africa), where courses previous rate of between 13 and 33 per cent. to less are given which lead to French State nursing diplomas.
UGANDA
Uganda is in east Central Africa; it is bounded on the south ber and January are the driest months.Western Uganda has by Tanganyika and Ruanda -Urundi, on the west by the Belgian a fairly uniform rainfall, with peaks in April and October.In Congo, on the east by Kenya, and on the north by Sudan.Most Acholi- Kyoga -Katonga the climate isfairly uniform, with a of the country is at an altitude of about 1350 metres; the central wet season from March to November.The average temperature plain is fairly flat but there are mountains on the periphery. of the country is 27° C.The total area is 243 411 square On the west the Ruwenzori range rises to over 5500 metres and kilometres,including 35 441square kilometres of swamps on the east is Mount Elgon (about 4500 metres high).There and water. are four climatic zones: the Lake area, around Lake Victoria; The population in 1957 was estimated to consist of about Karamoja; West Uganda; and the Acholi- Kyoga -Katonga zone. 5 610 000 Africans, 59 000 Asians and 9000 Europeans.The In the Lake area there is no definite rainy season but rainfall Africans are of three main races: Bantu, Nilotic and Nilo- is least in January and February and in June and July.In Hamitic. Karamoja there is a rainy season from April to August; Decem- Uganda isadministered by a Governor, assisted by an 146 FIRST REPORT ON THE WORLD HEALTH SITUATION
Executive Council of 11 ministers and the Resident, Buganda. there are many women's clubs and community centres in The territory is divided into four provinces (Buganda, Eastern, Uganda. Western and Northern), which are subdivided into 16 administra- tive districts.Each district is again subdivided into counties, Health subcounties and villages.Constitutionally Buganda is on a a different footing from the other provinces, since the Kabaka The health services are under the responsibility is a constitutional ruler.Responsibility for certain services of the Minister of Health.The administration of previously administered by the Protectorate Government has been transferred to the Kabaka's Government.The seat of the the Medical Department is carried out by the Director Government is at Entebbe but Kampala is the business capital of Medical Services.In addition, the government of the territory.African district councils have been set up in medical staff consists of one deputy director, two the Eastern, Northern and Western Provinces and are being assistantdirectors,14specialistmedicalofficers, given increasing responsibility.Kampala and Jinja are the only nine senior medical officers and 129 medical officers, two self -governing municipalities.There are over 100 other townships which have township authorities appointed by the of whom 42 are African. Governor. A senior medical officer in each province is res- Uganda is primarily an agricultural country. A copper and ponsible for health administration in general, and cobalt mine in the Toro district started production in 1956 and together with the provincial commissioner and other there are also tea plantations as well as fishing and salt industries. In south -west Uganda there are wolfram and tin mines and in the senior officers, forms a provincial team.The main Eastern Province a cement factory, a plant for the manufacture district general hospitals are in the charge of district of asbestos sheets, and the apatite and pyrochlore deposits of medical officers who also control the rural medical the Sukulu mineral complex are being exploited.Unemploy- centres and act as medical officers of health.In ment, as commonly understood, does not exist in Uganda and turn, they form part of a district team, much co- more labour is required than can be obtained locally.The main food crops are plantains and finger millet as well as sorghum, ordinated work being accomplished inthis way. beans, groundnuts, sesame, sweet potatoes, cassava and an The Kabaka's Government has assumed responsibility increasing amount of maize.The fishing industry is of growing for medical and health services in Buganda, although importance.Industrial expansion is based on hydro -electric many of the professional staff are at the moment power provided by the Owen Falls scheme, the eventual capacity of which will be 150 000 kilowatts.The notable increase in seconded by the Central Government.The Kampala livestock is due to effective disease control services.Forestry is and Jinja municipalities employ their own medical being developed. officers of health and inspectorate staff, but in all The Government's long -term education policy is to pro- other townships the government medical staff act videa minimum of four years' primary education for all on behalf of the township authorities. children. Education isneither free nor compulsory.There are at present about 1 250 000 African children of school age. Mission bodies, with some 1700 hospital beds, Higher education is provided at Makerere College -the Univer- provide a strong reinforcement to medical services, sity College of East Africa- and the Uganda Government and including the management of five leprosy settlements. African local authorities provide scholarships for education In 1957/58, 8.15 per cent. of the territory's total overseas. The Department of Community Develoment, under a com- budget, or nearly seven shillings (US $1.00) per head, missioner, a deputy commissioner and an assistant commissioner was expended on health services. (female) is responsible, under the African Minister of Social Medical and health staff included 371 registered Development, for community development and welfare, although medical practitioners (130 government, 241 private certain social development services fall within the scope of the and mission); 18 licensed practitioners (government education and medical departments.There are 25 community development officers, four of whom are African, and 20 posts of and mission, and a few on thelargerestates); African assistant community development officers, as well as 166 registered midwives (76 government, 90 private 161 African community development assistants.In the proba- and mission); 857 certified midwives (124 govern- tion and after -care service there are nine European and African ment, 733 private and mission); 161 senior health workers.In 1957, 690 men and 252 women passed through inspectorsand training courses at the Nsamizi Training Centre in Entebbe in healthinspectors(government); various subjects including local government, civics, commerce 10 government senior and 73 assistant laboratory and and so forth.Several rural training centres have now been x -ray personnel.The nursing division of the Medical established.The stimulation of the spirit of self -help and Departmentisheaded by a matron -in -chief and co- operation among rural communities for their own betterment comprises eight matrons, 13tutors,106 nursing continues to be an important aspect of the Department's work. Many improvements have been achieved, mainly at the local or sisters and health visitors, 405 nurses, midwives, village level; for example, the protection of water supplies, and nurse -midwives.The pharmaceuticalsection leprosysettlements,villageroads,building of workshops, has a chief pharmacist and six assistants.There bridges, etc. in which the people have usually contributed more are 21 registered dentists and eight licensed dentists. than half the total cost.Emphasis is placed on adult education and literacy, for which work four mobile book vans are used Nine dental surgeons and four dental mechanics are as well as radio and visual aids.There is a growing demand employed by the Government.There are, in all, from women for instruction in homecraft and child care, and 36 general hospitals and two mental hospitals, with AFRICAN REGION 147
a total of 5227 beds; 34 out -patient dispensaries; of the disease is the south -eastern corner of Uganda 213 dispensaries, with 7214 beds; and five leprosy bordering on Lake Victoria, where 167 new cases, settlements, with 1700 beds. of the rhodesiense type, were detected.The staff of Malaria is the largest single cause of morbidity the East African Trypanosomiasis Research Centre and is prevalent throughout a large part of the continue their research work by admitting cases and territory.Controloreradicationmeasures have by field investigations.Smaller numbers of cases were hitherto been limited to urban areas, where they are also noted in Mengo, Acholi, and West Nile districts. meeting with considerable success. The incidence of relapsing fever is steadily falling. The position in regard to tuberculosis will be No cases of yellow fever, plague, cholera or louse - better understood when the report is received from borne typhus were reported in 1957.In the same the WHO inter -country team which carried out year there were114 cases of poliomyelitis with sample surveys throughout theterritory in1957 seven deaths, compared with 72 cases and seven deaths and1958. A tuberculosisofficer was appointed in 1956: 5000 injections (compared with 12 000 in in 1955 to co- ordinate diagnosis and treatment and 1956) were administered.Smallpox in a mild form to supervise schemes of control. A medical advisory was reported from nearly all districts; in all, 477 cases committee assistsinover -allpolicymatters.In were notified, with four deaths.Sporadic cases of addition to the Mulago Hospital in Kampala, several typhoid fever occurred in most districts. districthospitalshave been supplied with x -ray A health education centre has been established facilities and special tuberculosis wards. under a senior medical officer, and various means Progress is being made in the treatment and control are being used for the promotion of health educa- of leprosy.The total estimated number of cases in tion of the public.Environmental conditions are the territory is 70 000, of which more than 30 000 are continually improving as regards both housing and now under treatment. A project of leprosy control, sanitation. A gradual and accelerated improvement partly in operation, consists of specially constructed in the traditional types of rural houses in particular treatment villages and of out -patient clinics where can be seen as a result of the work of various agencies, continuous treatment can be given. notably the Health and Community Development Bilharziasis is found in many parts of the territory. Departments. The distributionof Schistosoma haemotobiumis The training of local personnel has been under- found on the western shores of Busoga and in the taken in Uganda for many years.There are training southern part of Lango districts, both of which abut schoolsfor healthinspectors,medicalassistants, on Lake Kyoga.S. mansoni is found throughout nurses and midwives, assistant radiographers, pharma- the Northern Province and to a lesser extent in the cists and laboratory assistants.An effort is being Eastern Province and the districts of Bunyoro in made to expand local training to the degree required the Western Province.Direct preventive measures for the necessary personnel to staff the services covered are extremely difficult owing to the nature of the snail by hospital and rural health expansion programmes. breeding -ground. In East Africa higher educationisprovided at Nearly 900 new cases of onchocerciasis were treated Makerere College, which incorporates the Mulago during 1957.Surveys indicated that this disease is Medical School.In 1956 there were 224 Africans transmitted in many parts of the territory, in fact from Uganda studying in the United Kingdom and wherever running water and forests are found together. the Republic of Ireland in receipt of scholarships Simulium damnosum has been completely eliminated from the Protectorate or local governments.Forty - from the Nile area below Ripon Falls, Jinja.Re- eight more were in India, 47 of them with scholar- search is proceeding elsewhere into the best method ships, and a further 71 Africans were studying over- of controlling the breeding of S. neavei, the vector seas on their own. responsible in most of the hilly areas. The Virus Research Institute at Entebbe is one Nearly 500 new cases of trypanosomiasis were of the four main institutions of the Council for detected -three times as many as in recent years. Medical Research for East Africa,already men- The majority of these cases were of the mild gam - tioned in the reviews of Kenya (page 120) and Tan- biense type in North Lango.In addition to the ganyika (page 142).The work of the Institute includes usual control measures in this area, the Trypanoso- field epidemiology of virus infections, ad hoc surveys, miasis Control Department has sprayed dieldrin in and much laboratory investigation. A considerable a 6 per cent. solution on to the vegetation on the amount of individual research isalso carried out banks of the main river and its tributaries -a total by members of the Medical School on onchocerciasis, distance of 364 kilometres.The other major focus nutrition, bilharziasis, and on child health. 148 FIRST REPORT ON THE WORLD HEALTH SITUATION
The Medical Research Council of Great Britain recommended, inter alla, an increase of staff, expan- runs a unit for infant malnutrition in conjunction sion in training of local personnel, medical care and with the staff of Mulago Hospital. hospital services, maternal and child welfare ser- In 1955 a committee was appointed to examine vices,ruralhealth,statisticalservices,nutrition, the existing stage of development of medical and health education; and the formation of a central health services in Uganda and to make recommenda- planning authority.Successive phases of this develop- tions for future policy.The report of the committee, ment programme are expected to extend up to and which was largely accepted by the Government, including 1964.
UNION OF SOUTH AFRICA
The provinces of the Union extend from the southernmost the largest crops are wheat and maize.Sugar production is point of the African continent to the courses of the Limpopo, now expanding and fruit -growing has become a very large Molopo and Orange rivers -i.e., from 34 °50' to 22° south. export industry.Gold and diamonds are the most important They include all territories within those limits except Basutoland, minerals but there are also large supplies of coal.The principal Swaziland, Bechuanaland and part of Mozambique. The most imports are foodstuffs, cotton piece- goods, textile manufacture, southerly province contains many parallel ranges which rise motor spirit, motor cars and various types of machinery.The in steps towards the interior.Between the Great Swartling principal exports are gold, sugar, hides, fruit, wine, diamonds and Langberg ranges and the Roggeveld and Newveld ranges and various metals.Production is mainly in the hands of to the north lies the Great Karroo plateau.In the east are private enterprise, although several of the principal secondary ranges which join the Drakensberg mountains between Natal and industries are financed by the Government. the Orange Free State.The Orange Free State has a succession The direction of public education, other than higher education, of undulating grassy plains with good pasture -land and a general rests with the provincial education departments.Most Euro- elevation of some 1200 metres.The Transvaal is also mainly pean schools are State schools and most of the others are State - an elevated plateau with two ranges of no great height.Natal, aided.Primary education for all races isfree.Secondary to the east, has pastoral lowlands and rich agricultural land education is also free, with an age limit of 19 years in the Cape between the slopes of the Drakensbergs and the coast; the interior Province.The Union Department of Education, Arts and rises in terraces as in the southern provinces. Sciences has responsibility for the nine universities and for The climate ranges from Mediterranean and humid temperate technical, vocational and special schools. in the south to dry tropical in the north.The mean annual The chief ports are Cape Town, Port Elizabeth, East London temperature is remarkably uniform largely because the altitude and Durban.In 1954 the government -owned railways had a increases with the decrease in latitude, but both the annual length of nearly 22 000 kilometres, most of them of 3' 6" (105 and the daily changes of temperature increase with distance centimetres) gauge.There is now a through connexion from from the sea and with altitude.The rainfall is very variable Cape Town to the lower Congo and direct connexion with and generally decreases from east to west.The area is 1 223 409 Nyasaland by the Trans -Zambesia Railway.There are internal square kilometres. air services between all the chief centres of the Union, and a The population at the 1951 census was 12 667 759, of whom regular service between Johannesburg and London. 57.4 per cent. lived in rural areas, and the annual rate of increase The Department of Social Welfare administers a comprehen- in the same year was 2.10 per cent.The European population, sive scheme of relief and rehabilitation, and there are over estimated at 2 642 713, is of British, Dutch and some French 200 trained social workers attached to voluntary organizations. descent.The majority of the African population are Bantu In 1953, 1 602 000 persons were covered against accidents of (8 537 375); in addition there were 366 664 Asians and 1 103 405 employment, and 585 000 against unemployment. " coloured " (or mixed). The main occupations of the white population are agriculture, mining, manufacture and commerce, while the non -white races Health are principally engaged in agriculture and mining.Industry A Central Department of Health with headquarters absorbs rather more than 200 000 workers. in Pretoria undertakes advisory and executive duties Each province has a provincial council with power to legislate laid down by the Health Act.The Union is divided on certain specified subjects and on any others which may be delegated to it.The members are elected on the same system into the following six regions, each under the control as members of parliament.The administration is vested in of a chief health officer: Cape Western; Cape Eastern; an Administrator with an executive committee of four members. Natal; Orange Free State and the northern portion The provincial council has the same number of elected members of the Cape Province; Southern Transvaal; and as there are electoral divisions in the province for the House of Assembly but with a minimum of 25, and may raise direct Northern Transvaal.In addition to regional func- taxation for its own purposes. tions, the Cape Town and Durban offices control Although South Africa is the world's largest producer of gold, pathological laboratories. A biological control labo- and although there are other important mining industries, ratory and a vaccine institute are maintained at about 15 per cent. of the national income is derived from agriculture, fishing and forestry-a greater proportion than Cape Town. the revenue from mining and second only to that from manu- There are over 700 local authorities, which are facture.Wool is the most important single agricultural product; therealfoundation of thehealthorganization. AFRICAN REGION 149
Their services vary a great deal; on the one hand undertake inspection tours.At the end of 1955, there are the larger municipalities, such as Cape 1156 nurses were receiving subsidies. Town,Johannesburgand Durban,withhighly By far the most important problems of industrial organized health departments under the direction of hygiene at the present time are associated with the full -time medical officers, and on the other there gold- mining industry of the Witwatersrand.Com- are health committees and village councils under pensation for disabilities contracted in the mines is small teams of workers. a heavy drain on the resources of mining companies, The Union is fortunate in having assistance from but increasing advances have been made in industrial many voluntarybodies,notably the Red Cross hygiene, which ischiefly concerned with pneumo- Society, St John Ambulance and the South African coniosis. National Council for Child Welfare, as well as from The prevalence of paralytic poliomyelitis has been mission hospitals, religious associations and various increasing.Extensive epidemics occurred in1948 health services connected with the mines.On the and again in 1956, each of them with more than professional side the South African Medical Council 2000 cases.In the 1956 epidemic the change in and the South African Nursing Council are of great race incidence became apparent, with as many infec- importance to the health organization.Research in tions among the Bantu as among the whites, whereas epidemiology is undertaken by the South African in previous epidemics there were about 10 times Institute for Medical Research in Johannesburg. as many cases among the white population.Vaccine At the district level medical officers, known as is now being prepared on an increased scale in the district surgeons, are employed by the Government laboratories of the Poliomyelitis Research Foundation. in health and medical work; in the larger centres a Bilharziasis is endemic in many areas of the eastern few are whole -time but the great majority undertake half of the Union, and both forms occur, the incidence government work in addition to their private practice. beingdependent onlocalconditions.Intensive In June 1956 there were 446 district surgeons, of research is being undertaken by the State and other whom 59 were whole -time. organizations with theobject of controlling the The control of food, drugs, etc., rests with the disease. Department of Health, but localauthoritiesare Diphtheriastillconstitutes an important public required to co- operate in the executive work. healthproblem. Immunization hasbeen urged The smaller urban communities and rural districts repeatedly by the Government, but has not been are visited from time to time by medical officers generally adopted in spite of the fact that the Health of the Union Health Department.The larger urban Department is now entitled to give financial assistance areas employ their own technical officers, including to local authorities.Enteric fever is unfortunately medical officers of health and health inspectors, who still widespread, especially among the rural non -white are concerned with the whole range of environ- population, butitisbecoming progressively less mental sanitation. common in the large urban areas on account of The following vital statistics were recorded for the improved sanitation and water supplies.Inoculation European population in 1954: birth rate, 24.6; death against typhoid fever is free wherever the risk of rate,8.6; and infant mortalityrate,33.3.Very infection exists.Both bacillary and amoebic dysentery little change had been reported over the preceding occur sporadically, the latter especially along the three years. Natal coast. The provincial administrations are responsible for In 1924 the administration of leprosy laws was the provision of hospital accommodation, except in transferred from the Department of the Interior to respect of infectious diseases and mental cases.In the Department of Health. A Leprosy Advisory 1955, there were 45 649 beds in general and maternity Committee exists and a less rigorous interpretation hospitals, 6539 beds in infectious diseases hospitals, of segregation has now resulted in an increased and 20 029 beds in mental hospitals.There has number of leprosy patients seeking voluntary ad- been an extensive development of out -patient services mission to institutions.The introduction of sulfone in the various hospitals; in Cape Province alone, drugshasrevolutionizedtreatment;theclinical 1 174 868 out -patient visits were recorded in 1955, response is rapid and patients are generally fit for as against 1 034 337 in 1954. discharge within 12 months.The lepromatous cases The Union Health Department is responsible for which were previously regarded as incurable also subsidizing district nursing and midwifery services. respond to sulfones. A woman medical officer is in charge of this depart- In the past malaria was endemic in the river valleys ment at headquarters and specially qualified nurses and the coastal belts of Natal and also in the river 150 FIRST REPORT ON THE WORLD HEALTH SITUATION valleys and Low Veldt of the Transvaal, while it Venereal disease isstill one of the major health spread over wide areasin epidemic form.The problems and isespecially prevalent in the non- effective anti -malaria measures of recent years have white population of both urban and rural areas. reduced the incidence of endemic malaria to in- The Government provides special grants, amounting significant proportions.At one time severe epidem- to 871/2 per cent. of the net cost, for venereal disease ics of measles occurred, which caused a high death control schemes maintained by localauthorities, rate among the non -white population.This disease including clinics and hospitals.Similar assistance continues to be prevalent but its severity has decreased is given in rural health centres and stations, and a great deal in recent years.Pellagra is still fairly specific drugs are supplied free of charge. common among the poorer sections of the community, The South African National Council for Mental owing partly to the increased cost of living since the Health is a recognized representative body, dealing war and partly to the lack of health education on with prevention, after -care and mental health educa- suitable diet and food values. tion.The Council establishes mental health societies Mantoux and x -ray surveys have been conducted employing qualifiedsocial workers, who conduct for many years in all four provinces by the Union free out -patient clinics with the assistance of govern- Health Department.It is estimated that the inci- ment psychiatrists.The societies are autonomous dence of tuberculosis is: white, 0.5 per cent.; Asian, and independent bodies but receive financial assist- 1 per cent.; Negro, 2 per cent., and " coloured ", ance from the Council, which in turn is subsidized 2 per cent. A number of authorities and organiza- by a grant -in -aid from the Department of Health. tions assist in providing hospital beds for tuberculosis The Department of Nutrition, under the control patients, but all such buildings, as well as their of the Secretary for Health, co- ordinates nutritional equipment and maintenance costs, aresubject to research and undertakes the distribution of food- refund by the Government.The present -day tuber- stuffs under a special scheme operating in sub - culosis hospital bed position is as follows: economic areas, as well as controlling imports and exports of foodstuffs and administering the State - Union Health Department. . . 4 480 beds Provincial administrations . . . 510 beds aided milk and butter scheme. A National Nutri- Local authorities 1 930 beds tion Research Institute has been established by the Missions 3 102 beds Council for Scientific and Industrial Research. National Tuberculosis Association 3 496 beds There are five separate medical schools in the Private 1 003 beds Union, where provisionis made for students to Total 14 521 beds undertake a full course of studies leading to the degrees of M.B., Ch.B.The training of nurses and There has been an extensive development of facilities midwives is undertaken in provincial hospitals and for out -patient treatment of tuberculosis patients, provincial -aided hospitals. and approximately 40 000 tuberculosis patients are At the end of 1944, a housing amendment act being treated outside hospitals. was introduced creating a National Housing and At one time typhus fever was one of the most PlanningCommission.The Commissionisem- formidable epidemic diseases in the Union.Between powered to erect houses, to render technical and 1919 and 1923 an average of over 8000 cases was financial assistance to local authorities and utility returned annually.In the following eleven years, companies and to grant loans to individuals.Local up to June 1935, there were about 35 000 Negro authorities have also been given power under a cases and 700 white cases.The stage has now been slums act of 1934 to deal with the clearing of slum reached when the disease is no longer a public health properties and the acquisition of land for improved hazard. building.
ZANZIBAR
The Protectorate of Zanzibar consists of two islands: Zanzibar, most of the island's main products -cloves and copra -are with an area of 1658 square kilometres and Pemba, with an area produced.In the interior of Pemba the low hills are covered of 984 square kilometres, lying about 50 kilometres off the east with clove and coco -nut trees and rice is cultivated in many of coast of Africa.In Zanzibar there is a double range of low hills the marshy valleys.The climate is hot and humid, and there running north and south, with an uninhabited rocky plain to are two rainy seasons. the east and south and a fertile area in the north -west, where The 1948 census showed a population of 266 702, which rose AFRICAN REGION 151 to 299 111 in 1958.There is a seasonal exodus of labour from Apart from the keeping of hospital and dispensary the towns to country districts for clove -picking. statistics and the compulsory notification of certain There are three administrativedistrictssubdividedinto mudirias: four in Pemba and five in Zanzibar town. A few infectious diseases, there is no reporting of morbidity. local councils have been established. It is thought that a good deal of minor notifiable The economy of the Protectorate rests on the cultivation and disease remains unreported, as there are no medical export of cloves and coco -nuts.Staple food crops grown on practitionersoutsidethetowns.Theruraldis- the island are cassava, rice and bananas, but a considerable amount of food has to be imported. pensaries notify cases from time to time. The revised development programme ending in 1959 sets as In 1957 there were 10 hospitals in the Protectorate, its aim the provision of primary education for all boys in urban including one mental hospital, one for tuberculosis, areas and for 50 per cent. of those in rural areas. A four -year one for infectious diseases, and two leprosaria.There secondary course leads tothe Oversea School Certificate. were 22 dispensaries in Zanzibar and Pemba; of these Technical training is provided at the Mombasa Institute of Moslem Education, and in Zanzibar town there is a Trade School three have emergency beds, and one has a rural for boys and a domestic science training centre for girls attending maternity centre attached.During 1957 two new local schools.Government scholarships are awarded for higher dispensaries were erected in rural areas. education, at Makerere College in Uganda and in the universities Tuberculosis is treated in three general hospitals of Great Britain.Evening classes are held for adults. There is an advisory committee on education on which all in the Protectorate, as well as in the special tuberculosis races are represented.Teaching is carried out in Swahili in hospital.In 1957, there were 277 admissions of cases most primary schools, and thereafter in English, Gujerati being with tuberculosis, and 502 out -patients were seen at used in the Indian schools and Arabic in the Arab schools. the chest clinic.In all, 695 contacts reported at the There is no serious housing shortage in the Protectorate. New weekly " contact " clinic, and of these 144 were found rules on housing have recently been made to allow of stricter control in urban areas, and town planning schemes have been to be negative reactors to the tuberculin test.Of the drawn up. 144, 108 accepted and received BCG vaccination. The number of admissions to the leprosaria in 1957 Health totalled 47; three deaths occurred, and 59 patients were discharged.The number of cases remaining The Medical Department of the Protectorate is in hospital at the end of the year was 156. administered by the Director of Medical Services, who There are . no separate venereal disease control is a member of the Executive and Legislative Councils. clinics, but 3422 cases were treated as out -patients The health budget for 1957 was £276 844 (US $775 163), and 81 as in- patients in medical establishments in 1957. this being about 10 per cent. of the total budget The WHO team for the malaria eradication pro- and about £1 (US $2.80) per capita. gramme arrived in Zanzibar in1957, and initial At the end of 1957 public health personnel com- surveys prior to the spraying campaign were completed. prised 19 doctors, three dentists, 11 nurses of senior Only one case of smallpox was reported during training, 115 staff nurses, 12 laboratory assistants, the year.Vaccination campaigns were conducted in seven dispensers and 18 health inspectors. both islands, and 61 712 people were vaccinated. Doctors receive their training in the United King- During the year, 1098 schoolchildren were examined. dom, in India or in Uganda. A three -year course Of these, 30 per cent. had spleen enlargement, and for nurses, with an additional year for midwives, is 11per cent. showed evidence of anaemia.Itis provided at the government hospital in Zanzibar interesting to report that only five children were found town, and in 1957, 65 probationer nurses were under to be suffering from yaws. training. A training scheme for rural health workers Throughout the Protectorate thereis room for has been started with the assistance of a WHO tutor. improvement in rural sanitation, and itis hoped Training of entomological assistants has also started, that the situation may be improved when the rural under the direction of a WHO malariologist and ento- health workers have completed their training and are mologist. dispersed throughout the areas concerned.
REGION OF THE AMERICAS FIG. 7.REGION OF THE AMERICAS
VIRGIN IS. U.S. LEEWARD IS. QBAHAMA IS. GUADELOUPE Belize CUBA'Havana DOMINICAN REP. MARTINIQUE Ciudad Trujillo BRIT. JAMAICA
EL SALVADOR NICARAGUA San Salvador a nagua PANAMA COSTA RICA4: San José ALASKA
Alaska is the largest peninsula of the North American Conti- Health nent.It is bounded on the north by the Arctic Ocean and on the south and south -west by the Pacific Ocean. Canada lies on The responsibility for health and medical services its eastern frontier.Its area is1 518 775 square kilometres. rests with the Alaska Department of Health, under the Alaska is naturally divided into three well- defined zones: the direction of a Commissioner of Health, who is advised Pacific slopes, with cool summers, mild winters and a dense by a Board of Health.The Department has five main forest area; central Alaska with gently rolling uplands and sections in addition toits central administration: rugged mountains, light snowfall and rainfall; and Arctic Alaska, with a season of less than 40 days in which cultivation is possible. sanitation and engineering; maternal and child health The average annual temperature ranges from 6.6° C at Ketchikan services;mental health;nursing; and preventive to -12° C at Point Barrow, and the average annual rainfall medical services.Three regional offices carry out ranges from 450 centimetres at Latouche to 10 centimetres at this work through district health departments, each Barrow. with a district health officer, and local health units. The population of 128 643 at the 1950 census was composed The total expenditure of the Health Department of 94 780 non -indigenous peoples, 15 882 Eskimos, 14 089 In- for the fiscal year 1953/54 was US $1 608 000, or dians, and 3892 Aleuts, the last three groups being considered 6.4 per cent. of the total budget.In the preceding the indigenous people of Alaska.The estimated population in fiscal year, 1952/53, it was 6.8 per cent. of the total 1956 was 209 000. budget.The 1956/57 health budget of the territory The main economic assets of Alaska are fish, minerals, timber, furs, agricultural land, and water -power. of Alaska was increased to US $2 190 489 -i.e., by School attendance is compulsory for all children between the more than half a million dollars over that of 1954. ages of 7 and 16 who live within two miles of a school or school The vital statistics of Alaska show that in 1955 the transport.Correspondence courses are provided for all pupils birth rate was 35.2, a steady increase over the two who live too far from the nearest school.The Indian Field previous years, while the death rate was 5.8.The Service of the Department of Interior of the United States infant mortality rate for the same year was 37.8. Government maintains some one -teacherschoolsinthe In 1957 the medical and health personnel in the remote Aleutian Islands, besides its Wrangell Institute for territory were Indians. 196 graduate nurses; 49 public health nurses; two Adult education is provided by the Extension Service of the veterinarians;and ninesanitaryengineers.The Department of Agriculture and through the Department of following personnel were employed in the national Mines of the University of Alaska.Several school districts and privateagenciesalsoaffordopportunitiesforadult health services: 46 physicians; 10 public health nurses; education. 189 other graduate nurses; three graduate engineers; Living conditions vary widely from the Pacific slope towns, 14 dentists; 25 dental hygienists; two veterinarians; through the smaller communities in the north, to the small 32 laboratory personnel; four nutritionists; two social settlements of the Eskimos, Indians and the Aleuts.The workers; and one statistician,all full-time; at the varations depend on the situation of these indigenous groups provincial level there were six physicians; 39 public today rather than on their racial backgrounds.Racial discri- healthnurses;sevenothergraduatenurses; 11 mination does not exist, and the principal objective of the sanitarians;16 laboratory personnel; four health Alaskan Native Service is to integrate the three indigenous educators; seven social workers; and one statistician. groups, which together form 26 per cent. of the population, into There are no local health units independent of the the social, economic and political life of the territory.Wherever possible, as in the native schools, the direction and operation is territorialof Federal Governments.Local com- placed in their hands. munities contribute sums of money to the Depart- The housing situation was critical at the end of the war, with ment of Health, the amount being based upon the an influx of settlers adding to the military congestion already ability to pay. obtaining, and building costs rose to unprecedented heights. There is no medical school in Alaska, and students However, by June 1953 the Federal Housing Administration had therefore usually undertake their medical training in provided almost 6000 new houses and the Alaskan Housing the United States of America.The same applies to Authority had approved US $17 million in loans for another the nursing and technical personnel, although some 1300 houses, which were either completed or under construction. By mid -1954 there was no longer a housing problem in Anchor- midwives receive training locally from the Health age, Fairbanks and Kodiak, although in the territory as a whole Department. some need for single- family housing remained. In 1957 Alaska possessed 29 hospitals, with 996 beds; The social security benefits cover all workers in commerce and 28 general hospitals, with 748 beds, and one tuber- industry. culosis hospital.In addition there were 30 local - 155 - 156 FIRST REPORT ON THE WORLD HEALTH SITUATION health centres serving a total of about 200 000 people. ducted 32 midwives' classes during the same period, The services provided by the Department of Health and orthopaedic clinics were held at Mount Edge - include medical care facilities, preventive services, cumbe, Anchorage, Fairbanks, Juneau and Ketchikan. maternal and child health and crippled children's Twenty -six public health nursing stations were main- services, mental health, health education, sanitation tained throughout Alaska; 14 of them were in rural and medical social services, public health laboratories, and isolated areas, which are visited by public health and marine units. nurses.Twelve stations were maintained in com- Supplemental funds and specialized personnel are munities of 1000 or more.The 26 stations were contributed by the United States Public Health Service, staffed by 41 public health nurses, of whom 11 were which also operates an Arctic Health Research Centre maintained under contracts with the Alaska Native in Anchorage, through which it conducts studies and Service. investigations concerning health problems in low A central public health laboratory exists at Juneau, temperature areas. with regional laboratories at Ketchikan, Anchorage Among the communicable diseases, the case rates and Fairbanks. per 100 000 population for tuberculosis were reported The Alaska Cancer Society co- operates with the to be 488 in 1954, 457 in 1955, and 471 in 1956.Those Health Department in sending physicians to the for acute poliomyelitis were 49 in 1954 and 163 in United States to attend short courses in cancer 1955, while those for syphilis were 15 in 1954, 10.5 in diagnosis and treatment. 1955, and 12 in 1956. Nutrition presents problems in certain areas, parti- Vaccination against smallpox, and immunization cularly where food habits are in a stage of transition. against diphtheria, pertussis, tetanus and typhoid are Nutrition education is provided throughout the ter- given in all health centres and by all visiting public ritory and studies are being made on the utilization of health nurses. certain plants and animals for food. A recent noteworthy development in the mental Forty piped water supply systems serve 76 000 per- health services of Alaska was the Mental Health Act sons in urban areas, and 340 systems supply 59 000 per- of 1957, which placed responsibility for the care and sons in rural areas, mostly by means of public taps or treatment of Alaska's mentally ill directly upon the fountains or by private supplies.About 70 000 of the territorial administration.Furthermore, plans for a 77 300 urban population are served by 20 connected mental health hospital in Anchorage are on the sewage -disposal systems and 71 000 of 81 000 rural drawing- board, and the building is scheduled for com- population by latrines. pletion some time in 1963. Many of the communities have established health In 1953 -54, 661 child welfare conferences were held committees for public participation in the health in 121 organized communities.Travelling nurses con- programme.
AMERICAN VIRGIN ISLANDS
The American Virgin Islands are situated about 64 kilometres Education is compulsory for children from 51/2 to 15 years east of Puerto Rico and 2240 kilometres south -east of New York. of age.There is a Board of Education of seven members. They consist of the islands of St Thomas, St John and St Croix, A programme to improve teacher training was started in 1953 -54 and about 50 uninhabited islands and cays -a total area of with an enrolment of about 80 teachers.Two modern high 344 square kilometres.The climate is semi -tropical; tempera- schools, the first of their kind in the Virgin Islands, were opened tures range from about 20° C to 32° C, and the daily range of early in 1955.During the school year 1956 -57, approximately temperature is small. 6000 children attended the public schools and 2390 were enrolled At the 1950 census, the population numbered 26 665, of whom in private and parochial schools. A vocational rehabilitation 18 561 were Negroes.In 1956 the population was estimated at programme was started in early 1957. 30 051. The economy of the islands of St Thomas and St John is almost entirely dependent on the tourist trade; that of St Croix is primarily agricultural, and sugar -cane is the main crop. Health Cattle- raising on St Croix has been extended since 1955 as a result of the clearing of 21 185 acres (8573 hectares). The Department of Health (reorganized in 1958) The Virgin Islands Corporation, in co- operation with the comprisesthreedivisions :hospitaland medical Soil Conservation Service of the US Department of Agriculture, has increased the agricultural development of the islands by services,publichealthservices,andveterinary building dams on each of the three main islands. medicine. REGION OF THE AMERICAS 157
The reported vital statistics for 1954, 1955 and 1956 has been closed, all inmates having been declared were as follows: birth rate,30.3, 30.8 and 32.3; cured or arrested cases and released from the insti- death rate,10.4,10.7 and 11.9; infant mortality tution. rate, 38.7, 48.2 and 68.0. The principal communicable diseases reported in The public health services in 1956 were staffed by 1957 were trichuriasis, syphilis and ascariasis.No 21 doctors, 14 public health nurses, 51 other graduate cases of poliomyelitis were reported in 1956 or 1957. nurses, 88 auxiliaries, 20 graduate midwives, one gra- There are four maternal and child health centres, duate engineer, 12 sanitation personnel, three dentists, within reach of the whole population.In1956, five dental hygienists, 13 laboratory personnel, one 802 expectant mothers received pre -natal care: 2646 health educator, one nutritionist, two social workers, pre -natal and 752 post -natal visits were recorded; one statistician, and 205 clerical and other personnel - 5678 visits were made to children in their homes, allfull -time, with the exception of four doctors, and 9923 children visited clinics. one dentist and one dental hygienist who were working The islands have three water -supply systems serv- on a part -time basis. ing 2500 inhabitants; about 10 000 people are served There are three general hospitals with 188 beds, by public taps or fountains.Three sewerage systems providingmaternity,paediatric,tuberculosisand provide connected service to 8850 persons; 1500 have psychiatric services.There is also a home for the private septic tanks; 10 000 have latrines; and the aged with 150 beds.The Hansen's Disease Home remainder have neither septic tanks nor latrines.
ARGENTINA
Argentina occupies the eastern part of the southern area of co- ordinates the health work of the various govern- South America, extending from Bolivia to Cape Horn.The mountainous Cordilleras form its western boundary with Chile, ment departments with that of other institutions and and its long eastern coastline faces the Atlantic.In a country agencies.The fifth is a technical department, dealing covering such an extensive latitude there are great varieties of with problems related to the manufacture and sale of climate: mountain, dry- tropical, humid -temperate, semi -arid, drugs and other medicinal products. and even sub -polar.Of the total area (2 788 412 square kilo- Five advisory central councils were constituted metres) about 41 per cent. is pasture -land, 32 per cent. woodland (in the northern plains), and 11 per cent. cultivated land. in 1953 to deal with general health matters; health The estimated population at mid -1953 was 18 379 000 (Buenos education campaigns; maternal and child health; Aires, the capital, having nearly three million inhabitants); planning and co- ordination; and preventive medicine. in 1956 it was estimated at 19 485 869, with an urban population Vital statistics were as follows between 1953 and of about 61 per cent. of the whole.The people are mainly of 1956: European descent. 1953 1954 Argentina is an important meat -exporting country, and its 1955 1956 Birth rate principal source of income is from cattle -raising.In recent 25.0 24.1 24.0 23.8 Death rate decades cereal production has steadily increased and now pro- 8.8 8.2 8.6 8.2 Infant mortality rate. . . vides one of the chief exports.The main imports are machinery, 63.6 60.1 62.0 58.5 vehicles, fuel and lubricants, and manufactured iron and textiles. In 1952, there were 15 874 primary and 3233 secondary schools, At the end of 1956 there were altogether 689 hos- with about 2 445 138 and 509 608 pupils respectively.Argen- pitals in Argentina, of which 591 provided general tina has six universities, with a student population of over 90 000. services, 66 were reserved for tuberculosis patients, The railways, which are State -owned, have a total length and 25 were psychiatric hospitals.The total bed of 46 000 kilometres, and in 1952 there were some 4 000 000 kilo- capacity was 110 071, distributed as follows: metres of main roads.There are four domestic airlines, also General 52931 government -controlled. The main ports, Buenos Aires and Paediatrics 3885 Ensenada, are in the Plata estuary ; of the many river ports, Obstetrics 7855 Rosario and Santa Fe are accessible to seagoing vessels. Infectious diseases 3098 Other general services 5278 Health Tuberculosis 13125 Mental diseases 22003 In 1955, the Ministry of Social Welfare and Public Other 1896 Health set up five general departments, of which the firstthree deal with general medical and health In accordance with the programme of decentralization services,controlof communicablediseases,and initiated in 1950, when the regional health depart- environmental sanitation.The fourth department ments expanded the work of the hospitals, health 158 FIRST REPORT ON THE WORLD HEALTH SITUATION centres and health units,itis planned eventually training personnel to carry out mass BCG vaccination to provide 10 beds for every 1000 inhabitants. campaigns. In 1954, there were 21 973 doctors in Argentina, or In 1956, poliomyelitis gave cause for concern, since one doctor for every 840 inhabitants.By the end of 6496 cases were reported during the year.Special 1956, there were 25 500 doctors, and other health studies of the disease have been made at the Malbrán personnel included 10 083 dentists, 10 273 graduate Institute, where a pilot scheme for the production nurses, 16 527 other nurses, 3560 graduate midwives of gamma globulin has been introduced. and 2038 auxiliary midwives.Of these, the provincial A special division of the Ministry of Social Welfare health services and those of the municipality of Buenos and Public Health is in charge of measures for the Aires employed on a part -time basis 7660 physicians, control of eye diseases.An outstanding develop- 11 346 public health nurses, and 744 dentists. ment in this connexion was the organization of a The budget for the national public health services cornea bank, which started to function in1951. in 1953 was 667.6 million pesos (US $47 685 714 1), For the treatment of eye diseases in remote areas being 37 pesos (US $2.64 1) per capita and represent- where no special establishments exist for this purpose, ing 4.2 per cent. of the total national budget. 15 mobile ophthalmological units have been put into The campaign against Aëdes aegypti, which has operation, which provide both out -patient consulta- been in operation for some years, was continued, tions and surgical facilities.Furthermore, a factory although no new cases of yellow fever have been was opened in 1953 for the production of eye -glasses to reported since 1948.Vaccinations are given to the be provided free of charge to persons of limited means. inhabitants of the jungle regions in the north -east The Pan American Zoonoses Centre was established and north -west of the country.In the north -east in Argentina in 1956 - the Government of Argentina in 1952, Aëdes aegypti was found in 1060 houses out acting as host and providing buildings and other of a total of 11 752 inspected; as a result, 14 475 facilities - to serve the countries of the Americas vaccinations were given in this area.Studies showed in the control of zoonoses, by training personnel, that Aëdes aesculaparios and Psorophora ferox were conducting and co- ordinatingresearch,anddis- present, both of which are liable to transmit yellow seminating information.Within the country,this fever virus.Much valuable work in vector research work is carried out under the joint auspices of the has been carried out by the Institute Ministry of Social Welfare and the Ministry attached to the Malbrán Institute. Agriculture and Cattle- Raising.The Malbrán Ins- Improved standards of living and the consequent titute also co- operates by undertaking epidemiological improvements in hygiene have reduced the prevalence and endemo -geographical studies. of typhus to such an extent thatit isno longer There are six medical schools in Argentina, which considered a public health problem in the country; provide a six -year medical course leading to the degree the fewcases reported in recent years were all of physician; some 1800 students graduate from these imported. schools each year.On graduation, physicians who No human cases of bubonic plague were reported intend to take up general practice serve one additional duringtheperiodunderreview.An epizootic year of hospital internship, while those who select outbreak in the province of Buenos Aires was brought public health as a career must serve two or three under control immediately with the help of special additionalyearsofspecialization.Themedical legislation and control measures, which included schools, as indeed the other faculties of the universities, DDT spraying, destruction of rats, and construction are government -owned and charge no tuition fees. of rat -proof buildings. Candidates for admission must be in possession of Tuberculosis is a comparatively serious problem in the bachillerato, or secondary school certificate. Argentina; in 1956, 18 307 cases were notified, giving A special division of the Ministry of Social Welfare a rate of 93.9 per 100 000 population.As mentioned and Public Health is responsible for environmental already, there are 66 hospitals for the care of tuber- sanitation, and since 1953 sanitation teams have been culosispatients, and preventive measures include organized to assist the municipal authorities in this a BCG vaccination programme, in which the Ministries field.In 1956 it was estimated that the dwellings of of Education and National Defence co- operate with some 8 710 000 people in urban areas (44.7 per cent. the Ministry of Social Welfare and Public Health. of the total population) were connected to water - BCG vaccine production plants have been set up supply systems, and nearly six million people (30.3 in Buenos Aires and in Jujuy, and the Government is per cent. of the population) were served by sewage - disposal systems,allin urban areas. A further 1 Exchange rate prevailing on 30 June 1954 68.1 per cent. had private septic tanks or privies. REGION OF THE AMERICAS 159
BAHAMA ISLANDS
The Bahamas are an archipelago of islands, cays and rocks, 20 for infectious diseases, 60 for tuberculosis, and separated from Florida to the west by the Straits of Florida, and 200 for mental patients. from Cuba to the south by the Old Bahama and Nicholas Chan- nels.The territory has an area of 11 406 square kilometres and Medical and health personnel in the territory in comprises nearly 700 islands and over 2000 cays and rocks. 1957 included: 33 doctors, seven dentists, 88 graduate At the 1953 census the population was 84 841; in mid -1956 nurses, 15 other nurses, 10 midwives, 12 auxiliary it was estimated at 116 530, and at the end of 1957, at 130 698. midwives, and two veterinarians. The chief products are vegetables, fruit, timber, salt and fish, At the same time the personnel employed in the but the territory's economic prosperity continues to depend almost entirely on the tourist trade. health services of the Bahamas consisted of 22 doctors, Attendance at government schools isfree and compulsory 14 public health nurses, 32 other graduate nurses, from 6 to 14 years of age. five engineers, two sanitarians and 17 other sanitary. Two doctors, 12 midwives and 13 laboratory staff Health were on part -time service. The medical and health service is administered by a There are 25 health centres (23 in rural areas), Board of Health with the Chief Medical Officer as which carry out maternal and child health work.In adviser.In 1954, 8.9 per cent. of the total budget was the two urban health centres, 3812 women received allocated to health, an expenditure of £3 (US $8.40) pre -natal care and 10 295 children were attended per head.The proposed budget for 1958 amounted during 1957. to £459 750 (US $1 287 300). A school medical service was set up in1957, Births and deaths are compulsorily registrable, and a and the establishment of this vital service was probably number of infectious diseases are notifiable. Statistical the most significant advance of the year.Between returns for the territory as a whole cannot be con- September, when it commenced, and the end of 1957, sidered accurate, for many cases in the Out Islands are 3190 pupils from 11 schools in New Providence and not reported.Morbidity is estimated roughly by the 1018 pupils from 10 schools in the Out Islands were incidence of admissions to hospitals.The vital statis- examined.Thereiscloseco- operation with the tics for the years 1954 -57 were as follows: Education Department and the Bahamas Branch of
1954 1955 1956 1957 the British Red Cross. Birth rate 41.7 34.8 39.6 41.81 There is no medical school in the territory; medical Death rate 11.5 11.3 10.8 9.6 andotheradvancedtrainingisusuallytaken Infant mortality rate . . . 57.8 81.9 52.3 40.3 inthe United Kingdom.Nurses, midwives and Of the 460 medically certified deaths in 1957, 32 were " missionaries " (who work in the Out Islands) are due to pneumonia, 36 to diseases of early infancy, and trained at the Princess Margaret General Hospital at 14 to tuberculosis.The number of reported cases of Nassau.In 1954 the Bahamas Medical Association tuberculosis in 1955 was 82; in 1956, 109; and in 1957, encouraged its members to give more courses of 117; those of syphilis and its sequelae in the same advanced lectures to the nurses in hospital. period were 43, 21 and 19.Nine known cases of The city of Nassau, the capital in New Providence, leprosy are recorded in the islands, and all of them has a piped water supply and a sewerage system. are segregated. There are altogether nine water -supply systems in the Medical care is provided in four hospitals, with a territory, serving a total of 20 000 inhabitants, of total of 640 beds, including 30 for maternity cases, whom 12 500 live in urban areas.
BARBADOS
Barbados is an island in the Lesser Antilles of the Caribbean, The economy depends principally on the manufacture of sugar about 500 kilometres north of the coast of Venezuela.It has and molasses. There are also three rum distilleries, two iron works, an area of 431 square kilometres and a population in 1956 two ice factories, one bay rum factory and six bottling factories. of 223 000, of whom 93 per cent. are of African and 7 per cent. A five -year plan of development and taxation for the years of European descent.The population has increased con- 1952 -57 provides for the construction of a deep -water harbours siderably since the 1946 census, when it was 192 800. rehabilitation of the fishing industry, improvement of the strain, 160 FIRST REPORT ON THE WORLD HEALTH SITUATION of sugar -cane, and development of irrigation for agriculture. district and the southern district.Responsibility for The plan proposes a capital expenditure of BWI $16 500 000 health work will rest with the three Local Government (US $9 705 884) of which BWI $6 000 000 (US $3 529 412) is to be raised by loans, by recourse to the balance of funds Area Committees.In the meantime, the Director of available -including Colonial Development and Welfare funds - Medical Services, with the Senior Medical Officer of and by increasedtaxation amounting to BWI $1 500 000 Health, supervises the work of the parishes through the (US $882 353). six public health inspectors appointed to the General The adverse balance of trade in 1953 showed that the territory's imports of machinery, rice, flour, animal foods and Board of Health. cotton piece -goods exceeded by more than BWI $7 000 000 In1954/55thehealthbudgetamountedto (US $4 117 647) its exports of sugar, molasses and rum. BWI $1 662 000 (US $977 647), or 11.2 per cent. of There is no compulsory education, but it was estimated the total territorial budget, and BWI $7.3 per capita in 1954 that 98 per cent. of the population of school age were (US $4.29). enrolled in schools and that attendances averaged 75 per cent. Since the war the Housing Board has accomplished much in The birth rate in 1956 was 31.0, the death rate accommodating the growing needs of the inhabitants.Loans was 10.6, and the infant mortality rate was 96.7, amountingto BWI $2 559 316 (US $1 505 480)grantedto all three rates showing reductions from the 1953 rates, 6705 workers in the sugar industry, for building or repairing which were 33.1, 13.6 and 138.6 respectively. homes, have been provided from labour welfare funds.There is also an aided self -help housing scheme for the erection of Medical and health personnel in the territory's permanent homes in urban and rural areas. A pilot scheme for public health services in 1957 included: 48 physicians 15 three -room houses on land leased for 99 years was completed (of whom 18 were part- time), four dentists (part- time), in 1954.By the end of that year, 376 new stone houses had 15 public health nurses, 92 sanitarians, two veterina- been built and leased to poor families, and 737 families had rians, nine laboratory staff, and one nutritionist. been assisted to remove from unsuitable areas in the city to properly prepared sites. There are four hospitals in Barbados, all responsible Overpopulation and under -employment are the main social to the Department of Medical Services: the General problems in Barbados.Only during the farming season is there Hospital, with 416 beds and an out -patient attendance full employment, but unfortunately this does not last more than in 1956 of 98 741; the Mental Hospital, with 791 beds; five months of the year.After the harvest, a comparatively small proportion of the workers remain in regular employment; the Leprosy Hospital, with 17 patients; and the many obtain part -time work, while the others occupy themselves Maternity Hospital, with 20 beds.There are also with their own holdings.Since the war the United States of 11 parochial almshouses (one in each parish) with America has accepted increasing numbers of Barbadians for a total of some 1300 beds.Three health centres agricultural work; by the end of 1954 there were 1003 such - -at Enmore, Speightstown and Six Crossroads -are workers in the United States. responsible for all public health work undertaken in their respective areas.The health centres have already taken over the following duties in whole or in part: Health venereal disease control, tuberculosis control (including ambulatory treatment), maternal and child health The central authority for health is the Director of services,healtheducation,schoolhealth(dental Medical Services, who is responsible to the General services), immunizations, control of infectious diseases, Board of Health.On his staff are a senior medical and sanitation (supervision only). officer of health, a bacteriologist and pathologist, a A new quarantine station has been erected at port medical officer and several part -time medical Needham's Point, within easy access of the Port of officers.The local health services are composed of Bridgetown.At the latter and at Seawell Airport 11 Boards of Commissioners of Health, appointed quarantine measures are supervised by the health by each parish from the Vestry, or parish administration. officer, one public health inspector and two visiting Six public health inspectors supervise health work in the airport officers. parishes in co- operation with the local Vestries, which In 1956, diseases of the circulatory system were the also appoint their own health inspectors, the number principal cause of death, followed by diseases of early varying with the size of the parish.Parochial medical infancy, diseases of the heart, and diseases of the officers employed in each of the 11 parishes are nervous system.An Aëdes aegypti eradication cam- responsible for the provision of medical care to the paign was started in 1954; a BCG vaccination pro- needy and to the occupants of the parochial alms- gramme was started in 1956, and a mass venereal houses. disease control campaign has been planned.Diseases Under the new Public Health Bill of 1954, which is of nutrition were chiefly associated with vitamin B closely linked with the Local Government Bill but has complex deficiency. not yet come into effect, the island is divided into In 1956, free dental care was given to 6983 children; three areas: the city of Bridgetown, the northern 612 children were treated by an ophthalmic surgeon; REGION OF THE AMERICAS 161
825 infants were registered at the infant welfare Since there is no medical school in the territory, centres, with 2215 attendances at regular clinic sessions; qualification is normally taken in the United Kingdom. 1130 expectant mothers registered at the pre -natal Locally, training is provided for pharmacists in a clinics, and there were 5406 attendances at the regular three -year apprenticeship; nurses are trained in a clinic sessions.Public health nurses paid 819 visits four -year course, which leads to local certification; to the homes of patients. midwives have a training course of 12 -18 months, In1956also,the Baby Welfare League,the depending on whether the candidate has or has not St Lawrence Child Health Centre, the St Philip Baby completed the nursing course; and health inspectors Welfare Centre, the Christchurch Baby Welfare League are trained in a one -year course. and the Children's Goodwill League started clinic Two nurses from the Barbados General Hospital services and gave food supplements and meals to needy have been awarded fellowships at the University of children.The Barbados Nurses' Association -a pri- Colorado to do post -graduate training in tuberculosis vate organization- operated a nurses' employment and paediatric nursing. bureau and administered a government grant of The Government has started a programme for the BWI $4108 (US $2416) under the supervision of the improvement of rural sanitation.Pre -cast concrete Director of Medical Services.They continueto latrineunits have been supplied tolocal health employ three district nurses, who visit some schools authorities at 50 per cent. of cost (i.e., BWI $4.00 and give treatment for minor ailments, as well as (US $2.35) per unit), which has been met from advice in the homes. local funds.
BERMUDA
Bermuda, a group of islands about 1100 kilometres south -east The generalhospital - the King Edward VII of New York, is an important naval and air -base.Its area is Memorial Hospital - is privately run but is partially about 53 square kilometres with an estimated population in 1956 of 41 624.The main economic asset is the tourist subsidized by the Government.It includes depart- trade, which compensates for an adverse balance of trade. mentsformaternity,paediatrics,and infectious Agriculture being practically the only other activity, tenant diseases, and has a total of 162 beds.The two farms occupy some 80 per cent, of the land under cultivation, hospitals administered by the Medical Department although farming on the whole faces gradual reduction due are a small isolation unit (separate from the general to ever -increasing building development. Education is compulsory and free for all children between hospital), and a mental hospital with 164 beds. the ages of 7 and 13, although primary education is available In 1957, medical and health personnel in the terri- for children from 5 to 15 years of age.In 1955 there were tory included: 31 physicians, 18 dentists, 110 graduate 39 primary, 13 secondary and six vocational schools. nurses and four other nurses, 13 graduate midwives A housing shortage still exists, in spite of many projects carried out by the Housing Commission. and seven auxiliary midwives, four veterinarians and one sanitary engineer.Of these, the following were Health employed in the health services :seven physicians, The Medical Department isresponsible for the seven public health nurses, 92 other graduate nurses, public health and sanitation services provided by the one graduate midwife, one sanitary engineer, and two Government, as well as for the administration of dentists. two hospitals. The principal causes of death in 1956 were heart The health services budget in 1957 was distributed diseases, vascular lesions affecting the nervous sys- as follows: £5000 (US $14 000) for control of com- tem, cancer, and diseases of early infancy. municable diseases (including tuberculosis and venereal No cases of quarantinable diseases were notified diseases);£25 000 (US $70 000)forlocalhealth in 1956.Routine smallpox vaccination is, however, services, maternal and child health, dental health carried out, and 750 primary vaccinations were given and nutrition; and £225 000 (US $630 000) for hos- during that year.There are six known cases of lep- pitals and laboratory services. rosy (of whom one is segregated), but no new cases The birth rate was 27.7 in 1954, 25.8 in 1955, and have been diagnosed since 1947, when a case was 28.1 in 1956.The death rate for the same years was imported.Amoebic andbacillarydysenteryare 7.7, 8.2, and 8.1 respectively, and the infant mortality practically unknown, and diarrhoea is only occasion- rate was 37.8, 38.0, and 37.6. ally reported among infants. 162 FIRST REPORT ON THE WORLD HEALTH SITUATION
Tuberculosis control iscarried out at a special welfare clinics during the year, and 1426 visits were clinic, and there is also a mobile unit for this purpose. paid to children in their homes. The Tuberculosis Association, with a grant from The school medical servicecarries out regular the Government, undertakes mass x -ray examinations examination of schoolchildren. Among other findings, periodically; in the course of the third survey, in 1954, this service has estimated that six per cent. of the only 15 new cases were found.Furthermore, tuber- school population is poorly nourished.Free milk culin- testing among schoolchildren under 13 years distribution has proved effective in the more severe of age in 1956 revealed less than 5 per cent. positive cases.General nutrition studies suggest that mal- reactors. nutrition, where found among adults, is due to alco- Treatment of venereal diseases has been compulsory holism. since 1943.In 1956, out of 6022 serological tests Water supply presents some difficulties, mainly for syphilis, 1067 were found to be positive. because of the lack of sufficient piping facilities and Maternal and child health care is provided in nine the brackishness of some wells.With regard to centres, three in urban and six in rural areas.In sewage disposal, the city of Hamilton and the naval 1956,pre -natal care was given to 450 pregnant and air bases have partial sewerage systems, but women, and post -natal care was provided for 350 elsewhere all premises drain to individual disposal mothers:5963childrenvisitedinfant and child cesspits.
BOLIVIA
The Republic of Bolivia is one of the two landlocked countries At the regional level, each administrative depart- of South America, extending for 1 098 580 square kilometres ment of the country has its equivalent in a health through the vast lowlands which comprise three -fifths of the country, and the high plateau region between the two Andean district, in the charge of a chief medical officer, who ranges of the Pacific area which makes up the remaining two - is located in the chief town of the department and is fifths.Although the lowlands encompass some very fertile responsible for the district communicable diseases grazing land, three -quarters of the population live in the elevated control service, the departmental hospital, and all plateau region.With its average altitude of about 3000 metres, otherdistrictservices,suchas this plateau is one of the highest inhabited areas of the world. tuberculosis and At the 1950 census, the population was 2 704 165, of whom venereal disease control clinics, public health and 33.5 per cent. were urban and lived mainly in the principal cities sanitation, maternal and child health and school of La Paz, the capital (300 000 inhabitants), Cochabamba, health. A plan is under consideration for the group- Potosí, Santa Cruz, Sucre, Tarija and Oruro.The estimated ing together of these services into one integrated health population in 1956 was 3 235 251. Two -thirds of the population depend on agriculture, and centre at the district level, which would also include about 2 per cent. are engaged in tin mining.Tin, of which other health units that are at present run independently. Bolivian production amounts to about 15 per cent. of the Departments are in turn subdivided into provinces world output, together with lead, antimony ores, wolfram, for health as well as for general administration, the cocoa, hides and rubber are the main exports.Wheat, flour, sugar, iron and steel products, machinery and textiles are provincial medical officers being responsible to the imported.In 1952, three large mining groups, responsible for district chief medical officers.The provincial health about 60 per cent. of the total mineral output, were nationalized. service includes, in the chief town of the province, a dispensary, a pharmaceutical store, and sometimes Health a hospital with 10 -20 beds; its function is almost The Ministry of Hygiene and Public Health is in entirely to provide curative services, with the exception charge of most of the health activities of the country, of routine immunization against smallpox, whooping - with the exception of social security, which is dealt cough and typhoid fever.Control of certain com- with by the Ministry of Labour and Social Welfare, municable diseases, such as yellow fever, malaria, and industrial health, which is the responsibility of plague and typhus, in rural areas is in the hands of the Ministry of Mines.At the national level, imme- specializedpersonnelattachedtotheMinistry's diately under the Minister, there is a Director - General Division for Communicable Diseases.Some diffi- of Health in charge of the Health Department, which culty is experienced in recruiting sufficient medical includesdivisionsfortechnicalmatters suchas officers to take charge of the provincial services, communicable diseases, nutrition,vital and health although it is compulsory for medical graduates to statistics, maternal and child health, school health, serve for one year in the provinces before receiving dental health, and pharmaceutical products. their final medical degree. REGION OF THE AMERICAS 163
Budgetary difficulties have proved a considerable discontinued owing to the difficulty of reaching all hindrance to the orderly development of Bolivia's suspected sources, and a more effective method has health services.In 1954 only 4.8 per cent. of the been adopted of spraying epidemic foci.Cases of total budget could be devoted to health services, yellow fever were reported during the period - four although the health authorities estimate that 9 or in 1955 and six in 1956 - and the campaign for 10 per cent. would be required each year to cover eradication of Aëdes aegypti, which has been in pro- adequately the most important health needs.The gress for some years, is being continued.Plague, amount allocated to health represented a per capita which was introduced into the country within the expenditureof US $0.20in1954 and US $0.39 past thirty years or so, continues to give cause for in 1956. anxiety; nine cases were reported in 1954, and 45 In 1957 there were in Bolivia 38 general hospitals, in 1955, although there were none in 1956.There with a total of 4654 beds, six maternity hospitals are 200 known cases of leprosy, of whom 150 are (230beds),two paediatrichospitals(140beds), segregated in two settlements; much attentionis threetuberculosishospitals(329 beds), and one being given to the control of this disease, which is mental hospital (290beds).There were also 30 under the charge of a special section of the Health health centres which provided 247 beds for in- patient Department, and apart from the provision of further accommodation. Many of these hospitals are newly segregation facilities, emphasis is being placed on built and were opened during the period under health education of the public to prevent the spread review; one of them (with 280 beds) belongs to of the disease. theSocialSecurityService.Assistanceinthe Malaria is one of the principal causes of morbidity provision of medical care is also given by the Inter - in Bolivia, although control measures in the affected American Cooperative Public Health Service, which areas have helped to reduce the incidence from maintains independently 13health centres(sixin 672.4 per 100 000 in 1953 to 33.0 in 1956.Tuberculo- chief towns of departments and seven in smaller sis is also a serious problem; in 1955 and 1956 the towns) and five mobile rural health units. reported morbidity rate was 26.9 and 23.0 respectively, Medical and health personnel in Bolivia in 1957 and the death rate from this cause in 1956 was 55.6. included: 387 physicians, 17 dentists, 225 qualified The recent increase in accommodation for tuber- nurses and 401 other nurses, 32 qualified midwives, culosis patients in special hospitals (two new hospitals and three sanitary engineers,all employed either were opened in 1954) will undoubtedly be of assistance full -time or part -time in the national health services insolving the problem, and preventive measures at central, district or provincial level. being taken include BCG.vaccination, which was Social security measures have progressed in recent given to 2400 children in 1956.Cases of syphilis years, since the creation by law in 1949 of the National reported during the period numbered 381 in 1954, Social Security Fund under the Ministry of Labour 468 in 1955, and 306 in 1956.Treatment is provided and Social Welfare.Originally this Fund covered at all health centres and dispensaries. sickness and maternity benefits only for workers in There has been considerable progress in the exten- private concerns in the city of La Paz, but benefits sion of maternal and child health services in recent were later extended also to employees of the public years; a special section of the Health Department is services.In 1954 the total number of insured persons in charge of this work, and great emphasis is being and beneficiaries was 150 000. laid on education of mothers in the care of their In 1953, the vital statistics for the country were infants as one means of reducing the high infant reported as follows : birth rate, 37.6; death rate, 14.5; mortality.Maternal and child health care is provided and infant mortality rate, 106.1. in 34 centres, of which 13 are in urban and 21 in rural Of the quarantinable diseases, smallpox remains a areas.In1956, pre -natalclinics recorded16 957 persistent problem, with 624 cases in 1954, 372 in 1955, attendances, the number of pregnant women receiving and 481 in 1956; in the last- mentioned year, 117 903 care being 5092.In the same year, 226 584 infants primary and 153 045 secondary vaccinations were and children visited child welfare clinics, and 23 715 performed.Typhus is endemic in the cold zone children were visited in their homes. of Bolivia, from an altitude of about 2600 metres Most of the activities in environmental sanitation upwards, and occurs in epidemic form in various are carried out by the Sanitary Engineering Division localities from time to time; during the period under of the Inter -American Cooperative Public Health review incidence varied from 32.3 per 100 000 popula- Service, which has been instrumental particularly tion in 1954 to 12.4 in 1955, and 6.8 in 1956.The in theconstruction of water -supplysystems.In previous system of periodic DDT spraying has been 1956, 135 water - supply systems, all in urban areas, 164 FIRST REPORT ON THE WORLD HEALTH SITUATION provided piped water to 642 000 of the urban popula- that between 80 and 90 per cent. of the population tion -a percentage of 59.1.In the same year, live in satisfactory housing conditions.There is a sewage -disposal systems served 16.2 per cent. of the State housing scheme, operated through the social population, 8.5 per cent. of them in rural areas.Hous- security funds, whereby low -cost houses are built ing is not a serious problem in Bolivia; it is estimated for people of limited means.
BRAZIL
Brazil, the largest State in South America, has a coastline of prising fivelarge departments and four services : 7365 kilometres on the Atlantic Ocean and an area of 8 513 844 theNational Department of ChildHealth,the square kilometres.It is a country of great rivers and includes most of the Amazon basin and its tributaries, and in the south National Department of Rural Endemic Diseases, the includes much of the Paraná and Paraguay valleys. The northern Department of Administration, the National Depart- States of Amazonas and Para are mainly low fertile plains, the ment of Health, the Oswaldo Cruz Institute, the central Matto Grosso is principally plateau land, and the eastern Health StatisticsService,the Documents Service, and southern States are traversed by a succession of mountain ranges interspersed with fertile valleys.The climate is mainly the National Insurance Section, and theSpecial dry -tropical, although there are also wet -tropical and semi -arid Public Health Co- operative Service (with ICA). regions. The 1957 federal budget of the Ministry of Health At the 1950 census,. Brazil had a population of 51 944 397, amounted to 4 570 647 050 cruzeiros (US $68 218 613), of whom 61.7 per cent. were white, 26.5 per cent. were mulatto, a per capita expenditure equivalent to just over and 11.0 per cent. were Negro; there were also 329 082 Asians (0.6 per cent.) and 45 429 Indians.Rio de Janeiro, the capital, US $1.00, and included the following items : had a population of some 2.3 million; 36.2 per cent. of the total population lived in urban areas. Cruzeiros 1 The county is divided into 21 states, five territories, and the Health statistics service 6 560 200 Federal District, and is properly called the United States of Administration Department 929 748 100 Brazil, since each state has its own distinct administrative, National cancer service 220 660 100 legislative and judicial authorities, and its own constitution and National health education service 11 154 700 laws. National mental health service . 420 838 500 In 1950, agriculture accounted for 71 per cent. of the pro- National medical inspection service 28 940 900 ductive output; the total cultivated area in 1952 was 18 800 000 National leprosy service 191 702 700 hectares, of which 2 823 000 were for coffee.Brazil is an National tuberculosis service 460 761 700 important producer of coffee, castor beans, cocoa, sugar and Port health service 41 136 100 tobacco.The output of rubber in 1952 was 26 900 metric tons, Federal health delegations 14 985 700 and livestock production has much increased. Maternal and child health units. . 28 888 700 Mineral and forest wealth is also important.High -grade National Department of Rural En- quartz crystal, industrial diamonds, iron ore, chrome and man- demic Diseases 1190 713 600 ganese ore, monazite sand, and some coal are produced. Cotton -weaving has become the most important manufacturing 1 67 cruzeiros = US $1.00 industry. There is a large potential capacity for electric power produc- tion, although in 1951 the 2 million kilowatts produced were In 1955 there were altogether 2352 hospitals in probably not more than one -seventh of the potential.The Volta Brazil with a total bed capacity of 216 260; their Redonda plant, begun in 1948 with the aid of the Export- Import services were distributed as follows :1792 general Bank, is expected to supply Brazil with 59 per cent. of its steel hospitals, 110 for tuberculosis, 40 for leprosy, 53 for needs. 154maternity, 203 Primary education begins at the age of six and lasts for five paediatrics, and forother years, followed by four years of post -primary education at the specialties. Ginasio before entry to the Colegio, or secondary school, which The medical and health personnel in the country provides three further years of study in either classics or science. in 1954 included 23 195 physicians, 15 532 dentists, At the time of the 1950 census it was estimated that 49.6 per 16 563nurses,16 731nursing aides,1455 health cent. of the population over 15 years of age were literate. The Brazilian railway system is government -owned, as are visitors and 2989 sanitarians.Of these, 3725 doctors, 21 national airlines, and the largest national steamship company 770 dentists, 1422 nurses and all the health visitors with a tonnage of almost half a million. and sanitarians were employed in the health services. Vital statistics, which are available only for the Health Federal District and seven statecapitals, were as follows in the years 1954, 1955 and 1956: birth rate, The Minister of Health, advised by a Cabinet and 31.7, 30.7, and 30.1; death rate, 11.6, 11.6, and 11.9; a National Health Council, heads a Ministry com- infant mortality rate, 93.1, 98.9, and 100.3.Health REGION OF THE AMERICAS 165 statistics are in general also available only for these under supervision and treatmentatdispensaries. areas, and figures quoted in the following paragraphs The control programme includes early discovery and should therefore be taken as referring only to the treatment of cases, epidemiological studies, health FederalDistrict andsevenstatecapitalsunless education of the public in the present -day concept otherwise stated. of the leprosy problem, and various forms of social The principal causes of death in 1956 were diseases assistance to leprosy patients. of the heart (12 708 cases); gastritis, enteritis, etc. There appears to be an increase in the prevalence (9421); malignant neoplasms (6385); certain diseases of poliomyelitis, as 561 cases were reported in 1954, of early infancy (5761); and influenza and pneu- 368 in 1955, and 698 in 1956, the majority occurring monia (5016). in children under five years of age.Vaccination has Smallpox is a problem of some importance, as been initiated, and in Rio de Janeiro, Sao Paulo and illustrated by the number of cases reported in the one or two other state capitals, rehabilitation units areas for which statistics are available: 1035 in 1954, have been set up as part of the hospital services. 2580 in1955, and 2385 in1956. A large -scale Voluntary organizations are alsoassisting in the vaccination and revaccination programme is under rehabilitation of poliomyelitis patients. way, and during 1956, 1 292 250 doses of lymph were Malaria is an extremely complex problem in Brazil, distributed by the Ministry of Health; 816 908 vacci- and many cases still occur each year; the reported nations were performed during that year in the Federal rate per 100 000 inhabitants was 426.0 in 1954 and District alone.The campaign against yellow fever, 656.8 in 1955.The Government is receiving inter- which has been in operation for many years, was national assistance initscontrol effort, which it continued during the period under review, when proposes to convert into a nation -wide eradication reported cases numbered 12 in 1954, 22 in 1955, programme as soon as possible. and 16 in1956.The campaign includes control Yaws is widespread, and it was estimated in 1956 (with the object of eradication) of Aëdes aegypti; that there were some 600 000 cases in the country. vaccination of those portions of the population An eradication programme is in progress with inter- exposed to the risk of jungle yellow fever (1 267 216 national assistance, and in 1956, 143 106 cases and vaccinations were performed in 1956); a viscerotome 127 745 contacts were treated in a house -to -house service (with 1425 units throughout the country), campaign.The plan of eradication is based on the and epidemiological studies. A few cases of plague principle of coverage of more than 95 per cent. of have been reported (six in 1954, 27 in 1955, and four the population in affected areas, and includes training in 1956), all in rural areas, and control measures of qualified personnel and emphasis on health educa- are being taken in endemic or potentially endemic tion to obtain full participation of the people. zones, covering 160 municipal areas in seven states as Much emphasis is placed on the maternal and child well as the Federal District. health services, and every effort is being made to The programme of tuberculosis control covers al- extend these in order to provide adequate care for most the whole country, and the incidence reported the whole country.In 1956 there were 344 special in the areas for which statistics are available show maternal and child health centres in the country, the gravity of the disease :184.6 per 100 000 in 1954, and statistics received from 13states showed that 120.8 in 1955, and 171.7 in 1956.In the Federal care was given to 95 635 expectant and nursing Districtalonethereare87tuberculosiscontrol mothers and infants under two years of age, as well clinics and 14 mobile units; in 1956, 2 452 170 BCG as to 48 555 children of pre -school age. vaccinations were performed.For the whole country There are 23 medical schools in Brazil, of which there were,in1955,110hospitalsreserved for nine are national institutions; two are maintained by tuberculosispatients,withatotalbed capacity the State of Sao Paulo, nine are privately owned, of 22 801; by1957,the bed capacity had risen and the remainder are run by religious organizations. to 23 969. In 1954 there were 980 water -supply systems in the Leprosy is endemic in Brazil, and in 1956 there country, serving over 10 million people, or 16.8 per were 63 143 known cases (a rate of 105.5 per 100 000), cent. of the population.There were also 459 sewage - of whom 23 034 were segregated (mainly in leprosaria, disposal systems, which served 5 745 000 people, a but 803 of them at home), and the remainder were percentage of 9.6. 166 FIRST REPORT ON THE WORLD HEALTH SITUATION
BRITISH GUIANA
British Guiana lies on the north coast of South America, with Health Venezuela to the west, Brazil to the south and Surinam to the east.Geographically, the territory is divided into three regions: a coastal region, about 50 kilometres in width, which is the The Ministry of Health deals with allpolicies agricultural area; an intermediate area of slightly higher land, affecting the health of the community.The Central about 160 kilometres wide, which contains the chief mineral Board of Health administers all health matters under and forest reserves of the country; and a hinterland of small a Director of Medical Services and a Medical Depart- mountain ranges and savannahs.Although about 80 per cent. ment. of the land is well forested, only about one -fifth of this area is at Public health work iscarried out by the present easily accessible for lumbering. Town Councils of Georgetown and New Amsterdam, The area of British Guiana is 215 000 square kilometres and and by local authorities in the rural areas. at the end of 1955 the estimated population was 473 670, not The health budget in 1957 was BWI $5 311 462 including American Indians.According to 1954 estimates the (US $3 124 389), which represents 11.7 per cent. of population is made up as follows: 221 400 East Indians, 169 800 of African descent, 52 700 mixed, 19 000 American the total budget and a per capita health expenditure Indians, 8600 Portuguese, 4160 other Europeans, and 3450 of BWI $10.56 (US $6.10). Chinese. Vital statistics for the years 1954 -57 were as follows : For administrative purposes (including health administration) the territory is divided into five districts. The principal crops of British Guiana are sugar -cane, rice 1954 1955 1956 1957 and coco -nuts.There are large mineral deposits; the country Birth rate 42.8 43.2 42.3 44.51 is a major source of bauxite and produces considerable quantities Death rate 12.4 11.9 12.2 11.57
of gold and diamonds.The forests are its most important Infant mortality rate . 73.9 70.4 68.8 67.59 natural resource.Imports include machinery, textiles, flour and fish, while the chief exports are cane sugar, bauxite, rice, timber and gold. Medical and health personnel in the territory in In 1954, a two -year development plan was launched, based 1957 included: 122 physicians, 31 dentists, 787 gra- upon the recommendations of the International Bank for duate nurses, 694 graduate midwives and 10 veteri- Reconstruction and Development.Itis estimated that this narians.In the same year the national, provincial plan will cost BWI $44 000 000 (US $25 882 353); it will be and local health services employed 89 physicians, financed partly by territorial funds derived from loans, accu- mulated revenue and surplus balance, and partly from funds 63 public health nurses, 454 other graduate nurses, made available under the Colonial Development and Welfare 262 graduate midwives, 91 sanitarians, four dentists, Act of 1945. 10 veterinarians, 40 laboratory personnel, and three Drainage and irrigation projects are expected to reclaim much social workers on a full time basis.The senior medical coastal land foragriculture.In1953 -54 the Government staff is usually qualified in the United Kingdom, and initiated a programme for the purchase of machinery for hire to farmers. the Public Hospital in Georgetown is approved by The Department of Education administers primary education London and other universities and medical schools as well as supervising the administration of training, technical as a pre- registration hospital for six interns.Several and secondary schools.The entire staff of the Department of young men and women applied in 1957 and were Education is local or West Indian.Primary education is free and open to all children from 6 to 14 years. accepted for nursing training at their own expense The Government has earmarked for housing schemes some in the United Kingdom. The Royal Institute of BWI $2 000 000 (US $1 176 471), of which about one -third is Health in London holds examinations in the territory from Colonial Development and Welfare grants.Houses are to for public health inspectors and health visitors, the be built both by contract and by self -help.In 1954 the central training being given in the public hospitals of George- housingandplanningauthorityprogrammecompleted 275 houses, 80 self -help projects and 447 houses under contract. town and Berbice.Nurses, midwives, dispensers, On the sugar estates land lots have been mapped out for building chemists and druggists are also trained in the public and approved by the Central Board of Welfare.The use of hospitals in these two cities. wood in construction is being replaced by more permanent The number of hospitals in 1957 was 22, with a materials. In 1954, BWI $18 750 (US $11 029) were provided by the total bed capacity of 3186.There were 19 general Government for the development of youth groups.There are hospitals, which included provision for paediatric six district social welfare officers whose duties are to promote and maternity patients and cases of infectious diseases; the recreational and social activities of the villagers as well as they provided a total of 1687 beds, of which 74 were to encourage cottage and village industry.There are 21 village reserved for paediatrics, 91 for maternity and 51 for community centres organized by community councils.Women's groups have been developed in rural areas, and in 1954 there infectious diseases.There were also three specialized were 34 women's institutes. hospitals - one for tuberculosis (262 beds), one for REGION OF THE AMERICAS 167 mental disorders (832 beds), and one for leprosy A BCG vaccination campaign, with assistance from (405 beds).In 1953, there were 64 maternal and child WHO and UNICEF, began in March 1954; a follow -up health clinics, and four dispensaries with 26 beds for programme is now in progress. A malaria control light cases and for out -patients; by 1957, maternal programme, begun in1947, has continued.The and child health services were provided in 103 centres. number of malaria cases in 1947 was 15 490, compared In 1952 there was one mobile unit; by 1957, nine such with 4 in 1957. units were operating. Systematic lectures are now being given in health Under the Development Scheme, approval was education to elementary school- teachers at the Govern- given for a 40 -bed government hospital to be built ment Teachers' Training College.In tuberculosis, in the Corentyne, three cottage hospitals in various the British Guiana Society for the Prevention and districts, and a Mobile Dispensary Service in the Care of Tuberculosis does similar educational work. Lower Demerara Valley. In school medical examinations, the most frequent The following table shows the principal commu- defects found are dental caries, helminthic infestation, nicable diseases recorded in 1956 and 1957, and their scabies and signs of malnutrition.Children in need rates per 100 000 population: of extra nourishment are referred to the Education
Disease 1956 1957 Committee for school meals. A UNICEF School Syphilis 1180.0 524.0 Feeding Scheme has been in operation for several Whooping -cough 104.7 111.07 years; over 20 per cent. of schoolchildren receive a Typhoid fever 103.0 72.81 free snack meal throughout the territory, including Tuberculosis 39.5 38.20 the interior.The good results of this scheme are Leprosy 23.3 24.07 Yaws 12.1 2.18 demonstrated by the general physical and mental Malaria 8.7 0.80 improvement of the children during the past few years. Diphtheria 8.5 4.58 In 1954 a water -supply programme was initiated, Meningococcal infections . 6.4 * and 209 artesian wells have been constructed by the Acute poliomyelitis 0.8 19.81 Government in the coastal region, with service mains Infectious encephalitis . . 0.4 providing water to some 300 000 inhabitants of rural No information available areas.
BRITISH HONDURAS
British Honduras is in the Caribbean, its boundaries adjoining teacher -training school. A number of scholarships are provided Guatemala and the peninsula of Yucatan.It has an area of by the Government.The Extra -Mural Department of the 22 963 square kilometres.The greater partis covered by University College of the West Indies maintains a resident tutor forest; 72 per cent. is high rain -forest, 15.5 per cent. pine forest in the territory, who organizes adult education classes, study and dry savannah, 5.5 per cent. wet savannah and mangrove groups and lectures. swamp, and the remaining 7 per cent. is cultivated. The wiry There is a shortage of housing in all towns and villages.In grass of the dry savannah is very poor pasturage for cattle. Belize, there is a lack of suitable ground, and the Government is The northern part of the territory and the southern coastal carrying out a reclamation programme to provide more building plain are nearly flat, and are swampy near the sea.The climate space, and is also undertaking a housing and slum clearance is generally hot and damp, but not unhealthy, with temperatures scheme.There is a regular movement of workers from one ranging from 15° C to 27° C, tempered by the prevailing sea area to another, following seasonal employment in logging, breeze. chicle collection, harvesting and milling sugar, and harvesting The population at the 1946 census was 59 220, and was and processing the citrus crop. estimated in mid -1956 at 81 779.In 1946 the capital, Belize, had 21 886 inhabitants, and there were five other towns with populations varying between 1300 and 3450. Health The economy depends largely on forest products, which ac- counted for 77.8 per cent. of all exports in 1955.Agricultural The medical and health services are administered development is limited; with a few exceptions, notably citrus by the Director of Medical Services, with a senior fruit growing, cultivation is for subsistence. A third five -year staff consisting of a medical officer of health, a surgeon development plan came into operation in 1955, providing for, and 10 medical officers.In 1954, expenditure on among otherthings,expenditure on forestry,agriculture, health accounted for 7.6 per cent. of the total budget, fisheries and transport. School attendance is compulsory between the ages of 6 and 14, and represented an expenditure per head of BH $5.4 and there are 122 primary, nine secondary schools and one (US $3.78). 168 FIRST REPORT ON THE WORLD HEALTH SITUATION
Vital statistics were as follows for the years 1954- vaccinated during the latter year.Measles, on the 56: other hand, increased from a rate of 7 in 1954 to 81 1954 1955 1956 in 1956. Birth rate 42.0 43.4 45.5 Syphilis isstill a problem, with a rate of 148 in Death rate 11.4 10.8 10.0 1956- although this had fallen from 239 in 1954. Infant mortality rate . 93.5 99.3 69.0 Progress has been made intuberculosiscontrol, with a decline in incidence from 143 in 1954 to There are nine hospitals, with a total of 479 beds, 46 in 1956.In the latter year 3332 BCG vaccina- includingonehospitalreservedfortuberculosis tions were performed.There is only one known case patients (55 beds), and one mental hospital (100 beds). of leprosy in the territory. In 1957 there were in the territory 21 physicians, Maternal and child health services are provided seven dentists, 80 graduate nurses, 30 other nurses, at 20 centres, seven in urban and 13 in rural areas, 34 graduate midwives, 60 auxiliary midwives and covering the entire population.In 1956, these centres one veterinarian.The national health service em- recorded 9709 pre -natalvisits by 2209 expectant ployed on a full -time basis13physicians,eight mothers, 3000 post -natal visits, and a total of 9060 public healthnurses,75other graduatenurses, infants and children receiving care either by visits 24 auxiliaries, one graduate midwife, 11 sanitarians, to them in their homes (910 such visits were made four laboratory staff, one health educator, one nutri- during the year) or by attendance at clinic sessions, tionist and one social worker. Two dentists were of which 53 228 were recorded. employed part -time. There is no medical school in the territory, but There has on the whole been a decline in the nurses, midwives and junior dispensers are trained reported incidence of communicable diseases during in the hospital at Belize.Higher training in pharm- the period under review, with the exception of measles. acy is obtained in the United Kingdom. Malaria, the principal disease, had a reported case Approximately one -third of the population is served rate of 367 per 100 000 population in 1956 compared by the two water -supply systems of the territory, with 1613 in 1954.Whooping -cough dropped from a both in urban areas.There is no sewage -disposal rate of 898 in 1954 to 120 in 1956; 2226 children were system.
CANADA
Canada occupies most of the northern part of the North Scotia, British Columbia, Ontario, Quebec, Alberta and Yukon American continent.Its geography is dominated by the moun- Territory are the principal mining districts, producing gold, tain ranges running north and south of the western side of the copper, lead, nickel, zinc, asbestos, iron ore and uranium. continent and by the pre -Cambrian Shield on the east.Between Each provincial government is responsible for its own educa- them lies the vast northern extension of the North American tional system.Primary and secondary schools are publicly plain.There are six main regions determined by geographical controlled and primary education is universal and compulsory. conditions: the Appalachian Acadian region, the Canadian Illiteracy is negligible.There are seven provincial and 21 inde- Shield, the lowlands of the St Lawrence and the Great Lakes, pendent universities in Canada, 154 colleges and professional the interior plains, the Rocky Mountain region and the Arctic schools and 49 senior colleges.About 70 000 full -time students Archipelago.The climate in the east and centre presents are following courses of university standard. greater extremes than similar latitudes in Europe, cold con- Canals, lakes and rivers provide more than 3200 kilometres tinental conditions being predominant.The south -western part of navigable inland waterways.There are two extensive railway of the Prairies and the Southern part of the Pacific Slope are lines -the Canadian National Railway and the Canadian Pacific milder.In the north, the climate is sub -arctic. Railway.There are nearly one million kilometres of main The population at the census of 1951 was 14 009 429, and at roads.Civil aviation, which is controlled by a branch of the the 1956 census, 16 049 288.Ottawa, the capital, had a popu- Department of Transport, has a large continental service that lation of 202 000 in 1951, and there are 10 cities of over 100 000 is now extending rapidly to the north and west. inhabitants. The Canadian Unemployment Act came into force in 1941, Canada is a federation of 10 provinces and two territories and as now amended it covers all employees under contract (Northwest and Yukon).Each of the 10 provinces has a of service. separate legislature and administration, and is divided into counties, which may be municipalities or may contain them, according to their size. Health The manufacturing industries now predominate in Canada, but agriculture continues nevertheless to take an important Constitutional responsibility for health in Canada place; arable land is one of the great natural resources, and rests primarily at the provincial and local levels. Canada is one of the chief food -exporting countries.Nova At the national level,the Health Branch of the REGION OF THE AMERICAS 169
Department of National Health and Welfare is res- The division of responsibility at different levels of ponsible for implementing federal health provisions, government and between public and private agencies working with and through provincial, municipal and has demonstrated the need for an effective co- ordinat- voluntary health organizations throughout the country, ing body for planning.This role is carried out by and also for co- operating in international health. the Dominion Council of Health, which includes in This Branch comprises three directorates - health itsmembership theadministrative head of each services, Indian health services, and food and drugs. provincial health department.Its chairman is the The Health Services Directorate includes divisions for Deputy Minister of National Health and Welfare. blindnesssupervision, maternal and childhealth, The Council meets twice a year and acts as an agency civil aviation medicine, civil services health, dental for promoting joint planning between the Federal health, epidemiology, hospital design, industrial health, Government and the provinces, and between individual laboratory of hygiene, mental health, narcotic control, provinces.It also advises the Minister.The develop- nutrition, public health engineering and quarantine, ment of health planning in Canada has been helped healthinsurancestudies,immigration,andsick by two federal provincial projects - the National mariners'medicalservices.These divisionshave Health Survey of 1948 and the Canadian Sickness been divided into three broad groups, each under Survey of 1950 -51.Under the former, with the the direction of a Principal Medical Officer.The assistance of a grant, each province carried out Indian Health Services provide preventive services studies of its health services and its needs for the and medical and hospital care for Indians and Eskimos, future.Under the Sickness Survey an attempt was and in 1955 a division of Northern Health Services made to estimate the incidence and prevalence of was added to provide for the rapidly developing illness, accidents and permanent disabilities of all Northwest Territory.In 1954 this service operated kinds, the amount of medical, nursing and other health 18 hospitals, 33 nursing stations and about 65 health care received, and the volume of family expenditure centres for the 145 000 Indians and 10 000 Eskimos for the various types of health service. of Canada. The executive planning of health services in Canada At the provincial level the organization of the is primarily a provincial responsibility.The larger health services in Saskatchewan may be taken as an municipalities usually provide basic public health example.TheProvincialDepartmentof Public services, participate in the costs of hospital care; and Health is headed by a Minister of Health with a supply medical services to the indigent. A rapid Deputy Minister, advised by a Health Services Plan- development of similar services in rural areas has taken ning Commission and five branches :the Regional place through the organization of health units with Health Service Branch, the Medical and Hospital a full -time staff.These serve rural areas or groups Service Branch, the Psychiatric Service Branch, the of municipalities. Research and Statistics Branch and the Administra- At the local level the basic public health services, tive Service Branch.The Regional Health Service suchasenvironmentalsanitation,communicable Branch with its divisions of child health, communi- disease control, maternal, infant and school health cable disease control, dental health, nursing services, services, public health nursing, health education and nutrition, sanitation, and venereal diseases control, vitalstatistics,are provided mainly through local supervises services for eight different health regions. health units or departments.These are directed by The Medical and Hospitals Service Branch covers full -time medical officers of health assisted by nursing, hospital administration and standards, medical ser- sanitary and auxiliarystaff.At the end of 1954 vices,municipal medicalcare,rehabilitation,air there were 158 local health units or districts and 30 ambulance services, medical care in the Northern urban health departments serving about 11.5 million Administrative District, and the Saskatchewan Hos- people - more than 75 per cent. of Canada's total pital service plan.The Psychiatric Services Branch population. controls psychiatric hospitals and community psy- By 1957 there were 221 local health units or districts chiatric services.The Research and Statistics Branch (including urban health departments) serving nearly has three Divisions :Vital Statistics, Research and 14 million people out of 15.5 million in all provinces Statistics,andthePublicHealthLibrary.The except Newfoundland, Prince Edward Island, and the AdministrativeServiceBranchincludesrecords, two territories - for which data were not available. administration, organization and methods, personnel There has been a substantial advance in preventive and training, and the usual supplies services.The work notably in maternal and child health, nutrition, provincial laboratories and health education cons- and thewhole range of communicabledisease. titute two independent Divisions. Special emphasis has been laid recently on problems 170 FIRST REPORT ON THE WORLD HEALTH SITUATION of chronic illness and the rehabilitation of disabled public auspices in the three western provinces of persons. Saskatchewan, Alberta and British Columbia.Since In 1945 the Federal Government made a general offer 1947, Saskatchewan has had a comprehensive hospital of grants -in -aid to the provinces for health insurance insurance scheme providing virtually complete in- and included a broad post -war reconstruction pro- patient care.Itis financed by personal premium gramme.This offer was abandoned owing to lack contributions or taxes and general revenues, including of agreement over tax powers, and in 1948 the Federal part of the proceeds of a sales tax. A similar pro- Government established the National Health Pro- gramme was introduced in British Columbia in 1949; gramme to assist the provinces in building up health it is now financed by general provincial revenues and facilities and training personnel.Under the different statutory provincial and municipal hospital grants. grants of this National Health Programme, about In 1950, Alberta extended its assistance to the muni- C $160 million (US $160 million) have been spent on cipal hospital plans which have been in operation increased services by provinces, more than 14 500 there for many years.This scheme now provides health personnel have been trained and employed, substantial protection against the costs of hospital and at least 65 000 hospital beds have been provided. care for the great majority of the population.All New legislation was adopted in 1957 under which these provincial schemes with certain amendments the Federal Government will share with the provinces will be eligible for the proposed federal grant -in -aid, the costs of hospital care and laboratory and radio- provided that they are available to all residents of the logical diagnostic services, provided that such care and province. services are available to all residents of the province. In 1957, it was estimated that there were 17 400 A broad range of public and private plans has doctors in Canada.The medical and health personnel been developed in the different provinces, offering employed in the national, provincial and local health medical care on a pre -payment or insurance basis services, including those employed in hospitals oper- to the general population.Newfoundland has had ated by Federal Government departments (such as a scheme since 1934 which now covers half its popula- those for Indians, veterans, and the military), were tion.Similar schemes have been developed under as follows:
Medical and health services personnel
federal provincial * local * Category total
full- part- full- part- full- part- time time time time time time
Physicians 3027 843 1069 482 164 145 324 Dentists 396 223 6 35 9 52 71 Public health nurses . . 1919 170 - 424 1 1272 52 Other graduate nurses . 3605 2574 3 935 4 52 37 Auxiliary nursing staff . 4995 3484 - 1505 -- 6 Graduate midwives . . 5 -- 5 --- Graduate engineers . . 52 28 - 21 1 1 1 Sanitarians 1032 82 - 107 - 366 477 Other sanitarian staff . 30 12 - 17 - 1 - Veterinarians 275 223 - 8 - 34 10 Laboratory personnel . 1487 613 - 863 - 11 - Nutritionists 204 168 - 33 - 3 - Health educators . . . 25 -- 23 - 2 - Social workers 157 58 - 94 - 5 - Statisticians 32 6 - 24 - 2 - Dental hygienists . . . 22 17 - 5 - Clerical personnel . . . 3421 1866 - 1369 5 121 60 Other personnel ** . . 16653 7043 5 9588 3 13 1
Total 37337 17393 1083 15550 187 2085 1039
* Exclusive of the province of Quebec ** Includes pharmacists, physiotherapists, occupational therapists, x -ray technicians, etc., and for some provinces may include certain categories of physicians, nurses, etc. REGION OF THE AMERICAS 171
There has been a rapid expansion of hospitals Provincial and local authorities are vaccinating the since the end of the war.In 1955, there were alto- most susceptible age -groups free of charge as rapidly gether 1256 hospitals, with 169 020 beds, including assuppliesbecomeavailable.Apart fromthis 1043 general hospitals (95 412 beds), 55 maternity preventivework,severalprovincesprovidefree hospitals(1233beds),12communicabledisease treatment and rehabilitation.During 1955, about hospitals (1002 beds), 9 paediatric hospitals (1653 800 000 children received two or more doses of the beds), 63 tuberculosis sanatoria (14 962 beds) and vaccine.Although thegeneral incidenceof the 74 mental hospitals (54 758 beds).The development disease was low in 1955, the attack rates of paralytic of home care programmes (described later) is aimed poliomyelitis weresignificantlylower among the at reducing the present demand for hospital beds. vaccinated children.The reported case rates per Vital statistics for the years 1954, 1955 and 1956 100 000 population were 15.7 in 1954 and 3.8 in are as follows : birth rate, 28.5, 28.2 and 28.0; death 1956. rate, 8.2 for each year; infant mortality rate, 32.0, Concerning other communicable diseases, the re- 31.0 and 32.0. ported case rate for measles in 1956 was 348.1, for The main causes of death and their rates per 100 000 tuberculosis58.4,forscarletfever56.2, and for population in 1956 were : diseases of the heart (273.8), whooping -cough 53.0.No cases of smallpox occurred malignant neoplasms (129.9), vascular lesions affecting in the period under review. the central nervous system (90.0), accidents (57.5), Mental illness is still one of the foremost health certain diseases of early infancy (46.8), influenza and problems in Canada.The number of patients in pneumonia (35.4), congenital malformations (17.6) mental institutions increases each year, and by the and arteriosclerosis (14.6). end of 1954 had reached 68 157.At the present The Federal Venereal Disease Control Grant has time the provincial and federal governments are encouraged planning and uniformity throughout the laying emphasis on extensivediagnosticservices, provinces.Each province has a control division, active treatment in mental hospitals, and rehabilitation. and all offer free diagnosis and treatment at public Preventive and short -term therapy services are being clinics or under private physicians.The latter are expanded, through the development of community reimbursed by provincial agencies on a fee for service clinics and psychiatric units in general hospitals. basis.Case -finding and contact -tracing are carried Most of the cost is borne by the provincial govern- out co- operatively by provincial and local agencies. ments, but federal financial assistance is provided The incidence of venereal disease has been reduced through a special mental health grant, and joint during the last few years by improved treatment and planningisa function of the Federal -Provincial control procedures. Advisory Committee on Mental Health. In tuberculosis the death rate has been reduced In the maternal and child health programmes special greatly in recent years (0.9 per cent. of the total deaths attention has recently been given to the needs of pre- in 1956) and the number of new cases annually is mature infants, and pre -natal care services are being beginning to decline.(The reported case rates per extended. 100 000 population were 68.6 in 1954 and 58.4 in A national conference on therehabilitation of 1956.)The case -finding and rehabilitation services the physically handicapped was held under federal are provided jointly by voluntary tuberculosis asso- auspices in1951.This marked the beginning of ciationsandtheprovincialhealthdepartments. national co- operative planning for disabled persons, Chest x -ray examinations on admission to hospital since before that a number of voluntary and govern- have been widely developed and BCG vaccination ment agencies had dealt with the rehabilitation of programmes are conducted in some provinces.Free specialgroups.On the recommendation of this treatment of pulmonary tuberculosis is provided in conference,a National Co- ordinatorof Civilian Newfoundland, New Brunswick, Nova Scotia, Mani- Rehabilitation was appointed and a special branch toba, Saskatchewan and Alberta.Financial help was set up within the Federal Department of Labour. for provincial programmes is provided through a Agreements for co- ordination have now been signed FederalTuberculosisControlGrant.Increasing with all provinces but one, and programmes have attention is now being given to the rehabilitation of already been started in most of the provinces.Voca- the ex- patient and all provinces have special pro- tional training of the disabled has also been provided grammes. with joint grant agreement.Furthermore, a large So far as poliomyelitis is concerned, under the medical rehabilitation grant was added to the National Salk vaccination scheme the federal and provincial Health Programme to assist in equipment and em- governments agreed to share the cost of the vaccine. ployment, and in training qualified personnel. 172 FIRST REPORT ON THE WORLD HEALTH SITUATION
Cancer is the second most common cause of death persons no longer requiring medical care can be in Canada today.Educational work by voluntary discharged to their homes and kept under regular societies and the development of clinics have greatly observation. improved the outlook in recent years, and most The general planningof governmentresearch provinces have drawn up a special programme for policy is a function of the Privy Council Committee diagnosis and treatment.There are quasi -voluntary onScientificandIndustrialResearch.Medical cancer agencies in Ontario, Manitoba and British research activities are co- ordinated by an informal Columbia which provide diagnostic and treatment committee, composed of representatives of the various services.SaskatchewanandAlbertahavecom- federal research agencies concerned, which reviews prehensive programmes of free services administered applications for grants and exchanges information by the provincial agencies.Other provinces pay the on general research policy. cost of limited services.The National Cancer In- With regard to public water supply, general statistics stitute, a voluntary agency, co- ordinates and supports on Canadian waterworks offer the following informa- anextensiveresearchprogramme.TheFederal tion on municipal systems: Cancer Control Service shares financial assistance for these services on a matching basis with the provinces. Number of systems 1646 Voluntary agencies are leading the campaigns against Underground supplies 443 important non -communicable diseases such as arthritis Surface supplies 1204 Filtration plants 247 and rheumatism, cerebral palsy, and multiple sclerosis. Chlorinated supplies 571 They support clinicalservices,rehabilitation and Population served 9764000 research. Percentage of total population 65.1 It is generally recognized that the aging of Canada's population will have an increasing influence on the These figures do not include private supplies, federally scope of the health services.In 1955, 7.7 per cent. owned systems and the municipal systems in the of the population were 65 years or over.Plans for Yukon and Northwest Territories. theelderly - such aspublicassistance,housing, For sewage disposal, there are 866 systems serving employment,recreationandmedicalcare - are a population of approximately 8 318 000, representing being provided in a number of ways.All levels of 55.5 per cent. of the total population.There are Government and various non -governmental organiza- 533 sewage treatment plants and 315 partial treat- tions have undertaken some responsibility for the ment plants. needs of the old.There are also programmes for Both federal and provincialgovernmentshave the care and rehabilitation of the chronic sick and a been concerned with the pollution of rivers in Canada. great deal of medical research into the subject is now A recent investigation of pollution of the North being undertaken.Provisionisalso made by a Saskatchewan River led to the removal of much number of agencies for boarding and nursing attention. of the toxic industrial waste, and also to a more Comprehensive programmes for the aged poor are adequate treatment of municipal wastes in many in- in operation in four provinces, the costs being met stances.The condition of the Ottawa River, which largely by their governments.In addition, special receives waste products from municipalities on both facilities for the chronic sick have been established sides of the river as well as from various industries, in all provinces.In many areas chronic and convales- has also been a subject of investigation, and some cent hospitals are attached to general hospitals and improvement has been achieved.Under the auspices have rehabilitation services. of the International Joint Commission, a special A new type of service for the old - hospital home study has been made recently of boundary water care - has been set up in several centres.In one pollution in the St Clair and Detroit River areas. instance the home nursing service is provided by the This study was principally concerned with the effect public health nurses.The Victorian Order of Nurses, of industrial waste discharge on municipal water which is the main agency in Canada for bedside supplies.The Division of Public Health Engineering nursing in the home, is giving a greatly increased of the Department of National Health and Welfare proportion of itsservices to elderly patients and co- operates with the provinces in the study of many isusingrehabilitationmeasures.Similarly,the of these problems, and long -term plans have also home -maker's services are now being provided at been worked out to ensure adequate disposal systems a number of centres.Some provincesarede- for municipal and industrial waste in various parts velopingaco- ordinatedsystem by which older of the country. REGION OF THE AMERICAS 173
CHILE
Chile lies between the Andes in the east and the shores of the of field operations throughout the country, which, South Pacific in the west, and extends from the borders of Bolivia for this purpose, has been divided into 15 health zones. and Peru to Cape Horn.Its total length reaches 4480 kilo- metres, whereas the average width of the country is only 160 kilo- The eight technical departments at Headquarters deal metres.The total area is 741 767 square kilometres.The respectively with: medical care, epidemiology, ma- Andes run along the eastern frontier at a general elevation of ternal and child health and health education, environ- from 1500 to 4500 metres, with numerous peaks rising much mental sanitation, dental health, laboratories, phar- higher.The climate is arid in the north, changing to Mediter- ranean and west -maritime southwards. maceutical services, and general technical services. The population was estimated at 6 589 000 in 1956, with a In each of the health zones there is a chief medical density of 8 per square kilometre.The capital, Santiago, has a officer assisted by a Zone Technical Board and by an population of 1 507 000; the other cities with more than 50 000 Advisory Committee, the latter composed of repre- inhabitants are Valparaíso, Concepción, Temuco, Viña del Mar, sentatives of the community. Chillan, Talca, Antofagasta and Talcahuano.The principal In each zone there is at ethnic groups are the Spanish settlers and their descendants; least one regional hospital and a network of smaller the indigenous Araucanian Indians, Fuegians and Changos; hospitals.The health centres are the executive units the Mestizos; and European immigrants. at the heart of this organization, and they are in The arid zone of the north produces Chile's greatest wealth: charge of all medical care and public health services copper (36.8 per cent. of the world's reserves), gold, silver, nitrate, borate, phosphate, rock salt, sulphur and guano; coal for the population of a given geographical area, is produced in the south.Exports of these minerals more than usually coincident with the area of the administrative pay for the import of industrial machinery, chemical products district, or political subdivision of the country. and vehicles.In farming, wheat is the most important crop, In 1957 there were 224 hospitals in Chile, with a with potatoes next, although soil erosion is a serious hindrance to progress.However, more food is exported than imported. total bed capacity of 33 358.Of these, 168 were Education is free and compulsory for all children between general hospitals (17 468 beds), six were for pae- the ages of 7 and 15.Professional instruction is given in the diatrics (1535 beds), one was for gynaecology and State University of Chile, the Catholic University at Santiago, obstetrics (381 beds), 16 were reserved for tuberculosis the University of Concepción, the Catholic University of Valpa- patients (4272 beds), and three were for mental raíso, and the Universidad Técnica Federico Santa Maria at Valparaiso; secondary instruction is given in the National patients (3521beds).There were also30 other Institute of Santiago and in theliceos and colleges in the hospitals providing a total of 6181 beds. capitalsof the provinces and in some departments.The In the same year, the medical and health personnel percentage of illiteracy is 26 for the country as a whole, ranging employed in the national health services included from 14.5 in the urban areas to 40 in the more rural ones. A social security scheme provides sickness, maternity, old - 169 physicians working on a full-time basis in adminis- age, invalidity and survivors' benefits. tration, and a further 3721 working in the field on either a part -time or a full -time basis, 1069 public Health health nurses, 8038 auxiliary nurses, 569 graduate midwives, 44sanitaryengineers,816sanitarians, The National Health Service, established in 1952, 19 dentists, 39 veterinarians, 49 laboratory personnel, according to the law is " in charge of health protection 27 health educators, 230 dietitians, 596 social welfare by means of public health measures, social assistance workers, and 629 statisticians. and preventive and curativemedical care ".In The National Health Service budget in 1956 was practice, it is responsible for public health work for 27 000 000 000 Chilean pesos (US $43 902 439), repre- the whole population and comprehensive medical care senting 2 per cent. of the national income and 16 for the indigent and for beneficiaries of social insur- per cent. of the national budget.Considering as ance schemes.Its central administration is entrusted beneficiaries only the 75 per cent. of the population toaDirector -General,assistedby an Advisory receiving medical care, the expenditure per capita Board composed of representatives of the Faculty was 6000 pesos (US $9.75) during the year.Roughly of Medicine of the University of Chile (the State 76 per cent. of the money comes from the national University), the Colegio Médico de Chile, Parliament, budget, 12 per cent. from the social insurance fund, the associations of employers, trade unions, and the and 12 per cent. from interest on investments and Social Insurance Service.The Director -General dele- hospital services paid directly by the patients them- gates executive authority to two assistant directors, selves. one responsible for the co- ordination of policy and As mentioned above, the national health service is standards through eight technical departmentsat responsible for providing comprehensive medical care Headquarters, and the other in charge of co- ordination for beneficiaries of social insurance schemes.The 174 FIRST REPORT ON THE WORLD HEALTH SITUATION
Workers'SocialInsurance Fund covers,among but in the latter year 124 593 primary and 658 595 others,all manual workers, their wives, and their secondary vaccinations were given; both glycerinated children up to the age of 15; on the whole, this and dried vaccine is produced in the country. represents between 70 and 75 per cent. of the popula- Apart from the institutional facilities for the treat- tion.There is also a Servicio Médico Nacional de ment of tuberculosis already mentioned, there are three Empleados (preventive medicine and limited medical mobile units for the control of this disease. A BCG care for civil servants and " white -collar " workers), vaccination programme has been in operation for and separate medical services for special groups, such some years, and preliminary statistical data available as the military forces, the police force, prisoners, and at the end of 1957 show that during the period of railway employees working along the railway track. the campaign 929 481 persons were tuberculin- tested; There is, furthermore, an Accidents Insurance Fund ofthese861 270completedtheirexaminations. with its own medical services.Through all these Negativereactorsnumbered 461154,of whom services about 90 per cent. of the population are 460 024 were BCG- vaccinated. covered to a greater or lesser extent, leaving only a There are 69 centres which provide maternal and very small group which finances its own medical care. child health services, and they recorded a total of Vital statistics for the years 1954, 1955 and 1956 433 429 pre -natal visits in 1956, as well as 2 241 653 were as follows: birth rate, 28.5, 28.2, and 28.0; attendances at infant and child welfare clinics. death rate, 13.2, 13.4, and 12.7; and infant mortality One of the difficulties confronting the national rate, 115.6, 119.2, and 109.1. Government in its health work is the displacement of The study of mortality in Chile shows great changes inhabitants from the rural areas to the large urban in the past ten years.In 1948 the leading causes areas, causing constant disruption of its programmes of death were diseases of the respiratory organs, of control, immunization, education and personnel followed by tuberculosis, infections of the digestive trainingIn 1875 the urban and rural populations tract, diseases of the circulatory system, children's were 27 per cent. and 73 per cent. respectively, but diseases of the first year of life, nervous diseases, by 1952 this situation was reversed to 60 per cent. accidents and cancer.In the period under review, in the urban areas and only 40 per cent. in the the 10 major causes of mortality were: diseases of the rural. respiratory system, excluding tuberculosis (20 per There are four medical schools in the country, cent.), cardiovascular diseases (14 per cent.), infant to which students are admitted if they possess a diseases(13percent.),gastro- intestinaldiseases bachillerato,or secondary school certificate,with (11 per cent.), senility and ill- defined causes (8 per special mention in biology, and pass a written entrance cent), malignancy and tumours (7 per cent.), diseases examination.Three of the schools provide the full of the nervous system (6 per cent.), tuberculosis, all seven -year curriculum leading to the degree of Médico forms (5 per cent.), and infectious diseases, excluding Cirujano (Physician and Surgeon), but onlythe tuberculosis (2.5 per cent.). State -owned University of Chile is empowered to Of the infectious diseases, typhoid fever, whooping - hold the national examinations and deliver the final cough and diphtheria are the most important, with a degree.The fourth school has only recently been more or less stationary morbidity but receding morta- established. lity.Poliomyelitis shows a tendency to increase, In 1956 there were 285 water -supply systems in the with more serious outbreaks at two -year intervals; country, serving 46.4 per cent. of the population, of in 1954 there were 589 cases, in 1955 there were 416, whom 4.7 per cent. lived in rural areas.Ninety and in 1956 there were 719, the majority of cases sewage -disposalsystems were providedforover occurring in children under five years of age.No cases two million people, or some 32 per cent. of the popula- of smallpox were reported between 1954 and 1956, tion, 2.8 per cent. of them living in rural areas.
COLOMBIA
Colombia is the fourth largest country in South America and chiefly in the narrow valleys or isolated basins, each with its has the third largest population.It has coastlines upon both distinctive soil and climate and pattern of life. the Caribbean and the Pacific.Three -fifths of the country is The estimated population in mid -1956 was 12 939 140, with almost uninhabited lowland lying east of the Eastern Cordillera. a density of 11.4 per square kilometre.In 1951, 38 per cent. The great majority of the population (98.7 per cent.) is con- of the total population were urban.Some 45 per cent. of the centrated in the remaining, mostly mountainous, land, living working population are employed in industry, transport and REGION OF THE AMERICAS 175 commerce.About 30 per cent. of the people are of European hospitals was 502, with 40 153 beds; of these, 467 were descent, 40 per cent. are Indian, 15 per cent. mulatto, and 5 per generalhospitals(31 327beds), cent. African.The capital, Bogotá (census population in 1951, 16 were mental 648 324), lies 2650 metres above sea -level. hospitals(5911beds),and16 were tuberculosis Very little of the country is under cultivation, but much of the hospitals (2777 beds). soil is fertile and is coming into use as roads improve.The Local health services were provided in 657 munici- staple crops are rice, maize, wheat, barley, beans, potatoes, palities and included environmental sanitation, control cassava, plantains, sugar and panela, cocoa and tobacco. Cotton is grown on a small scale in most parts of the country. of communicable diseases, maternal and child health, Coffee accounts for 83.3 per cent. of the total export income, medical care, statistics, laboratory service, and health while petroleum accounts for 10.5 per cent.; the export of education. bananas is growing steadily.Cattle -breeding is a long -standing Important communicable diseases notified in 1956 industry in Colombia and one that is rapidly increasing the pro- included malaria (69 714 cases) typhoid and para- duction of meat, hides and milk.Exports of finished leather are expanding.Important mineral exports are gold, silver, typhoid fever(12 864 cases),tuberculosis(11 048 platinum and emeralds.There are large reserves of coal, iron, cases), syphilis (3167 cases), smallpox (2572 cases), salt and other minerals.Growth of industry has been rapid diphtheria (1278 cases), yaws (1154 cases), leprosy and national production now meets nearly all domestic needs in (789 cases), typhus (louse- borne, 77 cases; flea -borne, textiles, footwear, cement, building materials, beverages, cer- tain industrial chemicals, glass, tyres, pharmaceuticals, food- 672 cases), poliomyelitis (108 cases), rabies (18 cases) stuffs and tobacco. and yellow fever (16 cases). Primary education is free and is not compulsory.Besides A large -scale malaria eradication programme is the National University in Bogotá, there are 27 higher educa- under way.There were, in 1956, 50 tuberculosis tional institutions, of which 13 are in the capital.It was estimated in 1951 that 37 per cent. of the population over clinics and seven mobile units in charge of tuberculosis 7 years of age were illiterate. controlwork;391 726x -rayexaminationswere Vessels entering Colombian ports in 1955 had a net registered carried out, 7218 cases were diagnosed, and 1 138 930 tonnage of 9 076 887.Owing to the mountainous character persons received BCG vaccination.The estimated of the country the construction of arterial railways and roads is number of leprosy cases was 20 000; there were 9658 difficult.There are 17 different railway lines, with a total length of 3013 kilometres.The total length of motor roads in 1955 was known cases, of whom 6288 were segregated.The 26 458 kilometres.There is a large civil aviation service. number of persons vaccinated for the first time against smallpox reached 1 487 020, and those revaccinated numbered1 223 559.Theestimatednumberof Health cases of yaws was 40 000; 17 250 cases and 42 780 contacts were treated.In the control of yellow The Ministry of Public Health is composed of the fever167viscerotomecentresparticipated,and Minister of the standing Cabinet, a Secretariat -General 140 292personswerevaccinated.Approximately with administrative and legal sections, and a Section 188 000 children were vaccinated against who oping- for Evaluation and Statistical Co- ordination.There cough and diphtheria. are two main Divisions - one for Public Health and In 1956 there were 714 maternal and child health the other for Public Assistance.The Public Health centres, including general health centres with maternal Division has seven sections dealing with rural public and childhealth programmes;125 616 pregnant health and medical care, epidemiology and communi- women received ante -natal care, and 17 805 post- cable diseases, tuberculosis, leprosy, environmental natal visits were recorded.Furthermore,197 707 health, maternal and child health, and port health. infants and children were attended; 256 316 visits The Public Assistance Division has two sections, of children tothecentres, and 76 255 visitsto covering hospital and public establishments, and children intheir homes were recorded during the institutions of public utility.Directly attached to the year. Secretariat -General are also six sections in charge Of a total urban population of 4 415 257 in 1956, of professional practice, inter -American co- operative some 2 827 000 were living in dwellings connected public health services, and the Carlos Finlay and with a water - supply system, and a further 160 000 were Samper Martinez Institutes, as well as the Cancer served by other public or private supplies.Of a and Nutrition Institutes. total rural population of 6 873 921, about 531 000 The medical and para -medical personnel in the were served by private supplies. country in 1957 consisted of the following: 4500 Of the same urban population, 2 285 000 were physicians, 1500 dentists, 430 trained nurses (30 of servedbyasewage -disposalsystem,8491 had whom are public health nurse -midwives), 5800 auxi- cesspits, and 875 000 had latrines.Of therural liary nurses, 300 auxiliary midwives, 300 veterinarians population 220 000 had cesspits, and 596 000 had and 30 sanitary engineers.The total number of latrines. 176 FIRST REPORT ON THE WORLD HEALTH SITUATION
COSTA RICA
Costa Rica is the most southerly State of Central America. 1954 1955 1956 It lies across the Isthmus of Panama and is bounded by Nica- Birth rate 52.6 51.4 52.1 ragua and Panama and by the Caribbean Sea and the Pacific. Death rate 10.6 10.5 9.6 The coastal lowlands on the shores of the Pacific and the Carib- Infant mortality rate 79.3 82.0 71.6 bean are tropical, but the interior plateau, at a height of about 1200 metres, has a temperate climate.In most parts the soil The principal causes of death in 1956 were: gastro- is very fertile.The area is estimated at 50 900 square kilo- enteritis (1221 cases); certain diseases of early infancy metres. (1001); malignant neoplasms (747); diseases of the At the last census, in 1950, the population was 800 875, with heart (665), and influenza and pneumonia (554). an average density of 18 per square kilometre.The city of San José, the capital, had 86 909 inhabitants, and 66.5 per cent. Malaria is an important public health problem in of the population lived in rural areas.The country's population Costa Rica; the incidence reported was 149.6 (per in 1956 was estimated at 987 778. 100 000) in 1954, 114.6 in 1955, and 139.6 in 1956. Costa Rica is a republic, with a President and a single chamber Plans were made to convert the malaria control or Constitutional Congress.Members of the Cabinet comprise the two Vice -Presidents, and the Ministers for Foreign Affairs, programme into one of eradication, total- coverage Economy and Finance, Public Works, Agriculture and Industries, DDT spraying to begin in 1957 in the affected area, Interior, Education, Public Security, and Health. which covers some 31 500 square kilometres and has The economy of the country is primarily agricultural.The a population of 451 000.No cases of yellow fever principal agricultural products and exports are coffee (with an occurred between 1954 and 1956, although1951, average crop of 20 000 metric tons), bananas and cocoa.Maize, sugar and potatoes are also widely grown.Soil erosion is 1952 and 1953 had been epidemic years; vaccination serious.There is also some dairy -farming and cattle- raising. is concentrated on foci of epidemics when cases occur, Industry isstill on a small scale.The principal imports in and no vaccinations were therefore carried out during 1952 were chemicals, food, machinery, textiles and petroleum. this period.No cases of smallpox were reported, Elementary instruction is compulsory and free.There is a university in San José. but13 046 vaccinations against thisdisease were Two railway systems with a total length of about 800 kilo- performed in 1956. metres connect the capital with the ports on the Caribbean There were 252 known cases of leprosy in the coun- and the Pacific.There are about 560 kilometres of motor try in 1956, of whom 166 were segregated in a leprosy roads. settlement, which has accommodation for 177 patients. The remainder received out -patient care at two special Health treatment centres. A total of 21915 serological tests for syphilis were made in 1956, revealing 3215 positive cases. The Minister of Public Health is advised by a The incidenceof tuberculosisremainedfairly Technical Health Council and an Administrative stable during the period, being 70.6 (per 100 000) Council, and the Ministry, in addition to the usual in 1954, 71.6 in 1955, and 70.9 in 1956.There were administrative services, has two main departments : altogether 496 beds for tuberculosis patients in health health, and medical care and social welfare.The establishments in 1956, of which 191 were in a special technical sections in the Department of Health have tuberculosis hospital, and there was one mobile unit recently been grouped into three main divisions : for tuberculosis control.Of 47 702 x -ray examinations preventive medicine, maternal and child health, and carried out in 1956, 700 cases were found; 14 056 BCG environmental sanitation.The Department of Med- vaccinations were performed in the same year. ical Care and Social Welfareisresponsible for Poliomyelitis gave cause for concern during the hospitals, sanatoria, dispensaries and social welfare period under review, and reached epidemic proportions institutions. in 1954, when 1081 cases were reported; in 1955 there In 1957, the medical and health personnel of the were 45 cases, and in 1956, 170, the majority occurring country included 379 physicians, 113 dentists, 618 in children under five years of age.Vaccination of graduate nurses, 549 graduate midwives, 16 veteri- vulnerable groups of the population began in 1956. narians, and 12 sanitary engineers.In the same year There is a special rehabilitation centre in the country. there were 43 hospitals, with a total bed capacity of Maternal and child health services are provided in 5276; 18 general hospitals (3769 beds), 19 maternity 67 centres, and in 1956 pre -natal care was received by homes (282 beds), three mental hospitals (855 beds), 20 290 women; 436 268 infants and children were seen; onetuberculosishospital(191),one for leprosy of this number, 338 714 attended well -baby clinics. (177), and a pyretotherapy unit. Piped water supplies are provided through 60 The following table shows the vital statistics during systems in urban areas, and there are eight sewage - the years 1954 -56: disposal systems, also in urban areas. REGION OF THE AMERICAS 177
CUBA
Cuba is the largest and most populous of the West Indian The Directorate -General of Social Welfare isin islands.It is long and narrow -about 1170 kilometres in length charge of 46 hospitals, a dispensary, 13 blood banks, and with an average width of some 80 kilometres.The physical features of the island are very varied, ranging from high moun- and a dental health service.Hospitals have been tains, as in Oriente Province, to flat or rolling plains such as built in the town of Palma Soriano and in Antilla, those of Camagüey Province.Because Cuba lies in the trade - where there were previously none, and in the towns wind belt, the climate is humid, warm and equable. of Cárdenas and Guanajay new hospital buildings The population according to the 1953 census was 5 829 029, have been opened and are now functioning. with a density of 51 per square kilometre.The annual rate New of increase in 1953 was 2.07 per cent.The estimated popula- buildings have been completed and are shortly to tion in mid -1957 was 6 392 964, of whom about three- quarters be opened for the hospitals of Matanzas, Cienfuegos, were white and the remainder were coloured or mulatto. Santiago, Camagüey, Manzanillo, Victoria de las Havana, the capital, has a population of 789 765; other cities Tunas, and Gibara, as well as for the Mercedes with more than 100 000 inhabitants are: Holguin (226 779), Camagüey (191 379), Santiago de Cuba (166 384), Santa Clara Hospital, the Radium Institute, and the National (142 176), and Cienfuegos (99 530). Hospital in the city of Havana.The 13 blood banks The country is divided into six provinces, each with an are attached to the different hospitals which come elected Governor, and the provinces are subdivided into 126 under this Directorate -General.The crèches, hos- municipalities, each with an elected mayor.In accordance with the Constitution, they have complete autonomy in local gov- pitals and homes previously subsidized by this Direc- ernment. torate have been transferred to the National Corpora- The economy of Cuba is predominantly agricultural and the tion for Public Welfare.Complete data are not chief products are sugar, tobacco, sweet potatoes, bananas, rice, available on the total number of hospitals in the island. coffee and maize.In 1953, about 24 000 square kilometres In 1956 the health personnel of Cuba included: were under cultivation, of which about 60 per cent. were devoted to sugar -cane.Pineapples and citrus fruit are being grown to 6421 doctors, 2100 dentists, 2876 graduate nurses, an increasing extent, while the cultivation of bananas is decreas- 1885graduatemidwivesand700veterinarians. ing.Cuba has an important export trade in sugar and tobacco The public health services were staffed by 1458 doctors, and, to a lesser degree, in iron, copper, chromite and other nine public health nurses and 888 other graduate minerals. Education is free and compulsory between the ages of 7 nurses, 108 male nurses, eight graduate midwives, and 14.In 1950 there were 7614 elementary and primary 15 graduate engineers, 2023 sanitarians, 90 dentists, schools, with 596 469 pupils.According to the 1953 census, 54 veterinarians, 283 laboratory personnel, 19 health 22 per cent. of the population over 10 years of age were illiterate. educators, 14 dietitians, 25 social workers and 60 sta- tisticians. Health The death rates for all ages in 1954, 1955 and 1956 Under the Minister of Health and Social Welfare, were 5.9, 6.1, and 5.8 respectively. a Technical Under -Secretary and an Administrative The chief communicable diseases in1956, with Under -Secretary are in charge of eight directorates - their reported case rates per 100 000 population, general:health;socialwelfare;childguidance; were: syphilis (61.9); tuberculosis (31.0); typhoid fever the National Council for Tuberculosis; prevention of (16.5); malaria (2.1); diphtheria (2.7), and measles leprosy, syphilis and skin diseases; the Finlay Institute; (2.0). the National Corporation for Public Welfare; and The National Council for Tuberculosisdirects the National Institute of Health. laboratories and collects information for tuberculosis The Directorate -General of Health is responsible control, which is carried out through 28 dispensaries, for matters relating to : sanitation of ports and airports; five sanatoria and two preventoria.The 28 tuber- supervision and control of the practice of medicine culosis control dispensaries are distributed as follows and auxiliary professions (such as dentistry, veterinary in the provinces: Pinar del Rio, two; Havana, nine; medicine, midwifery,nursing, andlaboratory Matanzas, three; Las Villas, six; Camagüey, two; techniques); control over the importation and sale Oriente, six.Altogether 10 377 persons were exam- of drugs; control of food and drink; health statistics ined in these dispensaries in 1956, while another 12439 and epidemiology; control of venereal disease; dis- were examined by mobile units; 1333 x -ray examina- infection and environmental sanitation. tions were made, and 45 769 persons were vaccinated At the local level, each of the 126 municipal districts in the course of a BCG campaign. has a district health service which acts as a health The Directorate - General for the Prevention of centre and is under the direct responsibility of the Leprosy, Syphilis and Skin Diseases operates one Directorate- General of Health. dispensary in the Province of Pinar del Rio, three 178 FIRST REPORT ON THE WORLD HEALTH SITUATION in the Province of Havana, one in the Province of cultivation and livestock raising.The Institute has Matanzas, one in the Province of Las Villas, one in a number of special departments: a general hospital, Camagüey, and three in Oriente.It is estimated that a section for diagnosis and classification of disability, there are between 6500 and 7000 cases of leprosy two centres for basic education, and a social welfare in Cuba, of whom 4204 are under treatment, 731 of service.The Rehabilitation Institute for Girls -at them segregated in two leprosy settlements. Aldecoa-has departments for diagnosis and classi- Fifty -six cases of poliomyelitis were recorded in fication of disability, medical and dental care, and 1956, of which 41 occurred in children under five social welfare.Facilities exist for basic education, years of age. and tuition in music and elocution, needlework and There are eight maternal and child health centres, domestic science, and sports and physical training. which are run by the Maternal and Child Health and The National Institute of Health includes three large School Health Service, in the cities of Pinar del Rio, groups of specialized laboratories: one group for Havana, Matanzas, Cárdenas, Santa Clara, Cien- bacteriology, haematology, parasitology and serology; fuegos,Camagüey, andSantiago.They provide a second group for bromatology, hydrology, drugs, pre -natal and post -natal care of mothers and also biochemistry,and miscellaneoussubjects;and a hold infant welfare clinics. third group consists of biological laboratories for The School Health Service, which is attached to the preparation and control of biological products for the Department of Maternal and Child Health, is official use - such as smallpox vaccine (both gly- responsible for the health care of schoolchildren, cerinated and freeze -dried), typhoid vaccine, diphtheria teachers and other staff of educational establishments toxoid, etc. (each of whom has a health card), and for vaccinating There is one medical school in Cuba - the Faculty them against smallpox, typhoid fever, tuberculosis of Medicine of the University of Havana.Admission (with BCG), and poliomyelitis. is open to men and women who hold a secondary The Directorate -General for Child Guidance has school certificate and who pass the entrance examina- established a Section for Protection and Correction, tion.The course is of seven years' duration, and which includes a rehabilitation institute for boys leads to the degree of doctor of Medicine.About and another for girls.The Rehabilitation Institute 80 new doctors graduate each year. for Boys -at Torrens -has two centres, one for arts The Sanitary Engineering and Housing Section is and crafts and one for agriculture.The former responsible for the supervision and control of drinking - includes facilities for teaching elocution and music water, and of all matters connected with engineering and various workshops where the children learn and building works, including the approval or rejection shoe -making, mechanics, pottery, weaving, tailoring, of plans for the construction of private houses, public etc.Provision is also made for sports and games. establishments, industries, factories, workshops, water - On the agricultural side, instruction is given in crop supply systems, and others.
DOMINICAN REPUBLIC
The Dominican Republic shares the island of Santo Domingo as members of both the Chamber and the Senate and have also (formerly Hispaniola) with the Republic of Haiti, occupying held political, judicial, diplomatic and other public posts. the eastern two -thirds of the island.Its area is 48 442 square Ciudad Trujillo, the capital, had a population of 181 533 at kilometres, mostly mountainous and heavily forested.The the 1950 census, and in mid -1957 the number of inhabitants valleys north of the central mountain mass are very fertile and was estimated at 294 945.According to a census of buildings contain two -thirds of the population.The south is less fertile. and dwellings taken in 1955, 74 per cent. of the population are The climate is tropical in the lowlands and semi -tropical to rural, and 26 per cent. are urban. temperate in the highlands.The 1950 census showed the The cultivation of sugar -cane is the most important ele- population to be 2 135 872, with an annual rate of increase ment in the country's predominantly agricultural economy; of 2.45 per cent. and a density of 44.1 per square kilometre. 753 546 metric tons of sugar were produced in 1956.The Although the first settlers were Spanish, the census revealed central sugar refinery of Rio Haina is the largest in the world. that most of the inhabitants were of mixed European, African Coffee production has increased considerably and is the second and Indian blood; there were 601 000 whites, 245 000 Negroes, most important export commodity; the third most important and1 289 000 mixed. The estimated population of the is cocoa. Dominican Republic is mid -1957 was 2 703 656. Primary education is free and compulsory for children between Most of the population is engaged in agriculture.Women 7 and 14 years of age.It was estimated in 1956 that 40.1 per were enfranchised in 1942, and since then they have taken seats cent. of the population over the age of 15 were illiterate. A REGION OF THE AMERICAS 179 campaign is being conducted for the total eradication of illiteracy. hospitals with a total of 1250 beds, a psychiatric At the present time there are 4486 schools and 18 021 teachers, hospital with 1000 beds, and a leprosy hospital and including the special units for eradication of illiteracy. The Social Security Scheme is being extended and at the settlement with 250 beds are under construction. present time covers almost all the industrial workers in the There were 1403 physicians in the country in 1957 -a country and a large proportion of the agricultural workers. ratio of 1: 1926 population -as well as 411 dentists, At the end of 1957, about 200 000 workers were insured.The 316 graduate nurses, 460 assistant nurses, 52 graduate actual number of people covered is much greater than would appear from these figures, since the Scheme also extends to the midwives, 16 veterinarians, three sanitary engineers, families of beneficiaries in the form of maternity benefits and and 271 auxiliary health personnel. children's allowances. In the same year, 18 physicians were employed in the national service (medical staff in the Office of the Secretary of State for Health and Social Welfare), Health 37 in the provincial preventive medical service, and 49 in the local preventive medical service. A further In the Office of the Secretary of State for Health 512 physicians were serving in hospitals and other and Social Welfare there are, in addition to the usual State institutions for medical care.The health ser- administrative and legal sections, three departments vices also employed 20 public health nurses, 296 headed by Under -Secretaries of State : one for curative graduate nurses, 460 assistant nurses, 52 graduate medicine, one for preventive medicine, and one for midwives, three sanitary engineers, 271 auxiliary health social welfare.The first of these is responsible for personnel, 52 dentists, three veterinarians, 82 labo- the medical and nursing staff of the dispensaries ratory technicians,twohealtheducators,eight and hospitals through which medical care is provided. dietitians and four statisticians. The second comprises divisionsof epidemiology, As far as communicable diseases are concerned, the tuberculosis, sanitary engineering, malaria control, incidence of typhoid fever has decreased by 50 per cent. nutrition, organization of laboratories, health educa- during the past four years.There is some leprosy tion, health statistics, and provincial and local health in the country, although it is not widespread.Malaria, services.The third department directs the social which was the most serious health problem, has services (homes for the aged, assistance to the needy decreased to a very considerable extent in recent the child health and welfare years as a result of the control programme, which services(nurseries,crèches,orphanages,training has now given place to a programme of eradication. institutes for minors), and the nutritional services There has been a very marked drop in deaths from for adults and children. tuberculosis in the past few years, and a nation -wide Between 1952 and 1957, the national health adminis- campaign of mass BCG vaccination is to be undertaken tration did much to develop and organize the services in the near future in order to strengthen the existing of local health centres, to improve facilities for the control programme.In the experimental and demon- training of doctors, medical students and nurses -in stration area of San Cristóbal -which is representative short, to extend and improve all types of public of the country as a whole -the morbidity rate for health service. early syphilis (primary and secondary) was 14.3 per The total budget for the national, provincial and 100 000 inhabitants in1956.The distribution of local health services in 1957 was US $13 305 387, or yaws in the country presents a somewhat uncommon about 9 per cent. of the total national budget.This picture of residual foci limited to certain localities figure includes the budget of the Dominican Social in rural areas; for this reason the prevalence of this Security Fund.The sum invested in hospital con- disease cannot be estimated on the basis of figures struction (US $4 306 606.40 in 1957) is not included obtained in the areas already surveyed, where it has in the budget of the Secretariat, as it is derived from been found to be low. A programme of eradication additional funds which also cover the cost of equip- is at present being undertaken, and it is hoped that ping the new hospitals. the disease will have completely disappeared by the In 1957 there were altogether 66 hospitals and end of 1959. sanatoria in the country.Of these, 49 were general In 1956 there were 15 reported cases of paralytic hospitals with a total of 5214 beds; two were paedia- poliomyelitis, of which 13 occurred in children under tric hospitals; nine were maternity homes; two were five years of age. special hospitals for the treatment of tuberculosis In addition to the maternity homes and paediatric (586 beds), and one was a psychiatric hospital with hospitals, the following centres provide services for 220 beds.The total number of beds in government maternal and child health and welfare : 28 establish- hospitals is at present 7264. A further six general ments which give advice on infant nutrition and diet 180 FIRST REPORT ON THE WORLD HEALTH SITUATION
(these have an annual attendance of some 5000 infants State.These services cover an urban population of under one year of age); three nurseries with accom- 600 418 and a rural population of1 005 769.In modation for 500 pre -school children; two crèches rural areas, 916 527 people draw their water from with cots for 150 infants, and three training institutes public fountains. or reformatories, for minors, with accommodation There are four sewage -disposal systems,allin for 410 children.In 1957, 60 supplementary feeding urban areas, which serve some 400 000 inhabitants. centres distributed 10 511 900 bottles of milk and The rest of the population uses septic pits and indi- 1 348 600 loaves of bread to 24 803 persons of limited vidual latrines. means -mainly pregnant women and needy mothers The Dominican Republic has a Faculty of Medicine, of large families. founded at the end of the 16th century, which is There are orphanages for minors of both sexes, affiliated to the University of Santo Domingo.The with accommodation for 500 children, and six homes medical course lasts six years and leads to the degree for the aged, with 573 beds.Pensions arealso of Doctor enMedicina;studentsmust holda paid in cases of invalidity, extreme poverty and secondary school certificate with specialization in senility. physics and biology.In 1957 the teachingstaff About 60 per cent. of the population are provided of the Faculty numbered 41, and 944 students of with piped water supplied through 51 urban networks, both sexes were enrolled.Of a group of 150 stu- which also serve certain neighbouring rural areas. dents who began the course at the same date, there There are seven exclusively rural networks, and were 66 candidates for the degree.The University 325 rural water -supply systems maintained by the is a State institution.
ECUADOR Ecuador lies across the Andes at their narrowest point, with fever, yaws, rabies, venereal diseases and malaria; Colombia to the north and Peru to the south.It is largely and maternal and child care.There is an inspec- mountainous and is watered by the Upper Amazon and by smaller rivers on the Pacific coast. torate; and the Department co- operates with the The climate is dry -tropical in the west, wet -tropical in the Ecuadorian leagues against tuberculosis, cancer and Amazon region or " Oriente ", and mountain -dry in between. leprosy. The Humboldt current makes it cooler than might be expected, The MCH division has its headquarters at Guaya- The population was estimated to be 3 944 382 on 1 July 1957 as compared with the figure of 3 202 757 recorded in the first quil, with a sub -officein Quito and consultative national census of 1950.Mestizos comprise 41 per cent. of the committees in both towns.Its work is divided into inhabitants, Indians 39 per cent., whites 10 per cent., and school health, nursing, health centres, social service mulattos, Negroes and othersthe remainder.Quito is the and health education.Guayaquil and Quito each capital, with a population of 209 932. have two health centres, and there is one in each The economy is mainly agricultural, with cocoa and bananas forming the principal crops and exports.Coffee, rice, wild of the following towns: Cuenca, Portoviejo, Loja, rubber, mangrove bark for tanning, alligator skins, kapok, gold Esmeraldas, Ambato, Sangolqui, Cayambe and Lata- and silver are also exported and the cultivation of cotton, cunga. tobacco and sugar is increasing.Salt production is a govern- In 1957 the Republic had 1325 practising physi- ment monopoly. At the time of the 1950 census, 43.7 per cent. of the population cians, 351 dentists, 194 graduate nurses, 183 graduate over 10 years of age were illiterate. midwives and 32 veterinarians.Of these, the follow- Primary education is free and compulsory for all children ing were employed by the national, provincial or between 6 and 12 years of age. local health services: 94 physicians, 75 graduate Social security covered 107 000 in 1951 for sickness, maternity nurses; six graduate midwives; one graduate engineer; benefits, old age, invalidity and survivors' pensions. 23 dentists, all part -time; 14 laboratory technicians; fourhealtheducators;10dietitians;fivesocial Health workers; and 23 statisticians. There are 77 hospitals in the country, including The Directorate -General of Health is part of the 53general,four paediatric,threematernity, five Ministry of SocialSecurity and Health.Ithas infectious diseases, nine tuberculosis, and two mental technical divisions for international health; health hospitals. statistics; epidemiology and control of communicable In 1956, the birth rate in Quito was 46.0, the diseases;sanitaryengineering;the national cam- death rate was 15.0, and the infant death rate was paigns against tuberculosis, plague, typhus, yellow 108.1.During the same year the principal infectious REGION OF THE AMERICAS 181
diseases reported, with their case rates per 100 000 21 dispensaries, 19 health inquiry centres and two population were: tuberculosis, 116.4; typhoid fever, mobile units; in all 145 005 inhabitants were examined 41.6; smallpox, 17.7; malaria, 17.2; diphtheria, 14.2; by x -ray and 3874 cases of tuberculosis were dis- typhus, 5.3; and plague, 2.2. covered; 70 145 persons were vaccinated with BCG During1956,68 754 inhabitantsreceivedfirst during the year. smallpox vaccinations, and 220 270 were re- vaccinated; There are three medical schools in Ecuador, all 16 691 people were vaccinated against yellow fever, government- owned, which conferadegreeafter almost all in jungle areas; 4541 cases of yaws were a seven -year course.Admission is open to students estimated to exist, of which 541 were treated.Tuber- of both sexes with a secondary school certificate. culosis control work was carried out by 18 clinics, Approximately 200 students graduate each year.
EL SALVADOR
El Salvador lies on the Pacific coast of Central America, The central office has eight divisions: epidemiology, bounded by Guatemala, Honduras and Nicaragua.It is very includingmalaria and venerealdiseasecontrol; mountainous, and contains many volcanic peaks, some still active.The lowlands along the coast are generally very hot, laboratories; sanitary engineering; tuberculosis; local but the plateau and hills inland are cooler.There is a wet services; maternal and child health; health education; season from May to October and a dry season from November and a demonstration area providing for the training to April.The area is estimated at 21 393 square kilometres, of personnel and field investigation work. 71 per cent. of which is under cultivation. The population at the 1950 census was 1 855 917; with a For local health administration, the Republic is density of 110 per square kilometre.In mid -1957 the popula- divided intoseven regions, which have between tion was estimated to be 2 350 201, 36.5 per cent. of whom were them 15 health or sanitary centres and 20 health units. urban.The capital, San Salvador, had in 1955 a population of There isone mobile unit.During 1956 -57 these 195 000.Women gained full suffrage in 1950. institutions rendered a total of 141 684 consultations The economy of the country is predominantly agricultural, and heavily dependent on the coffee crop, which furnishes about in maternal and child health. 87 per cent. of the total exports.The area under coffee in The budget of the Ministry of Public Health and 1953 was about 1300 square kilometres mostly owned by Salva- Social Assistance for 1957 was 18 339 823 colones dorans.Other export crops are cotton, rice and maize.Gold (US $7 335 929); about 50 per cent. of this sum was and silver are also exported.The forests have mahogany, cedar, walnut, and balsam trees.El Salvador is the world's spent on hospital and medical care services, the rest principal source of balsam.In 1956 a dam was completed beingdevotedtopreventiveandsocial welfare which was designed to double the country's production of services. electricity -from 31 000 to 62 000 kilowatts -and a second dam In 1957 there were 23 hospitals in the country, with has been added to the system. a total of 5039 beds; 2345 of these were in general According to the 1950 census, 57.8 per cent. of the population over 10 were illiterate.Some headway is being made in reducing hospitals,506 for paediatrics, 487 for maternity, this percentage, and in 1954 there were seven centres for adult 1318 for tuberculosis, and 383 for mental illness. education.Primary school education (of six years' duration) In 1957, there were in the country 325 doctors, is provided free of charge, and is compulsory for children from 117dentists,401 graduate nurses,1183assistant 7 to 12 years of age.Secondary education lasts for five years. The University of El Salvador, founded in 1847, is an ad- nurses, 12 veterinarians, and seven sanitary engineers. ministratively autonomous institution financed almost entirely The following personnel were employed in the public by the Government. health services: 111 doctors (of whom 29 were engaged A new social security law came into force in January 1954 full- time), 144 public health nurses, three graduate under which employers pay 50 per cent. of the contributions for insurance, and the employees and the State pay 25 per cent. engineers, 127 sanitarians, 41 dentists (of whom 16 each. were engaged full- time), 39 laboratory personnel, 12 health educators, two dietitians, and three statisticians. Health The following table shows the vital statistics for the years 1954 -56: The General Health Directorate, under the authority of the Ministry of Public Health and Social Assistance, 1954 1955 1956 Birth rate 48.1 47.9 47.0 is responsible for all public health services in the Death rate 15.0 14.2 12.4 country. Infant mortality rate 82.4 76.7 70.3 182 FIRST REPORT ON THE WORLD HEALTH SITUATION
During the same period the principal causes of the possession of the higher secondary school certi- death and number of deaths were as follows: ficate, an entrance examination, and a certificate of good health. 1954 1955 1956 In 1956 there were 260 water -supply systems for Gastro- enteritis 5 486 4888 3465 the 730 000 inhabitants of urban areas, although Accidents 1 617 1717 1970 Malaria 852 955 642 these systems were not complete.About 300 000 of Tuberculosis 476 456 361 the urban population were served by a connected Cancer 486 426 439 system, 370 000 by public taps, and 60 000 by private Cardiovascular diseases 636 507 496 fountains.Of the1 270 000 people living in rural areas, public taps served some 100 000.In 1956/57 In 1956, nine ambulatory clinics examined some theGovernmentspentabout1 000 000colones 90 700 people for tuberculosis, and 1533 cases were (US $400 000) and 500 000 colones (US $200 000) diagnosed. BCG vaccinations were given to 7169. respectively for new waterworks in urban and rural About 18 doctors graduate annually from the areas. medical faculty of the University of El Salvador, Sewage -disposalsystems(25incomplete urban where annual admissions average about 40.In 1957, systems)served some 660 000 urban inhabitants there were 251 medical students, including 28 women, in 1956; in rural areas 200 000 of the total 1 270 000 in the University.Admission requirements include population had latrines.
FRENCH DEPARTMENTS IN AMERICA
On 1January 1947 Martinique, Guadeloupe and French square kilometres.Cayenne, the chief town, has 15 000 inhabi- Guiana became French departments, completely integrated with tants, or more than half the total population of the department. metropolitan France and enjoying the same status as the ninety More than 80 000 square kilometres are covered by Amazon continental European departments. forests with many different species of vegetation, which are very Martinique and Guadeloupe are in the Lesser Antilles; difficult to exploit since living conditions there are almost although in the tropics, their climate is tempered by the trade impossible.Only in a comparatively narrow strip between the winds, which blow regularly all the year round.The tem- forest and the marshy coastal area is cultivation practicable. perature remains comparatively stable with an average of 26° C; The most important productions are gold, timber, rosewood annual rainfall is from 2 to 3 metres according to the region. essence, and rum.The possibility of working the bauxite French Guiana lies on the north coast of the South American deposits which exist is at present under consideration. continent, bordering on Surinam to the north and on Brazil to the south.It is covered by vast forests of the Amazon type and has a very humid typically equatorial climate with annual Health rainfall varying between about 3 and 6 metres according to the area.However, the northern trade winds keep the temperature between 25° C and 32° C according to the region and the time The health organization in these departments is of year. the same as in any other French department, 2 but Martinique (with an area of 1080 square kilometres) and the relative importance of the different health services Guadeloupe (1780 square kilometres) are overcrowded terri- varies according to conditions and local needs in a tories; the former has over 240 000 inhabitants, with a density of 222 per square kilometre, while the latter has over 230 000 tropical climate. inhabitants, or 129 per square kilometre.Their production is The hospital situation has improved very much mainly agricultural.Sugar -cane, bananas and pineapples are inrecentyears.In Martinique, the number of the chief crops, and the economy of Martinique and Guade- hospital beds rose from 1580 in 1952 to more than loupe is closely linked to the industries processing these products 2000 in 1957, and during the same period the number (including sugar refining, rum distilling and pineapple canning), and the export trade derived from them, of which 90 per cent. of beds in hospices rose from 360 to 900.At Le is absorbed by France.In return, more than 80 per cent. of Carbet sanatorium the number of beds for tuber- the imports come from other French departments.There are culosis patients increased from 90 to170, and a no mineral deposits, and industrial development is very difficult thoracic surgery unit has been established.The bed and has been carried out only to a very limited extent.On this account, overpopulation raises extremely delicate economic capacity of Colson psychiatric hospital has risen from and social problems.There is a trend towards emigration to 200 to 400 as a result of extension of the hospital France, but not on a sufficient scale to provide even a partial buildings.Several maternal and child health centres solution to the problem. with accommodation for deliveries were opened in French Guiana on the other hand is very sparsely populated, 1956, and others are under construction. with approximately 29 500 inhabitants in an area of 91 000
Comprising Martinique, Guadeloupe and French Guiana 2 See under France (European Region). REGION OF THE AMERICAS 183
In Guadeloupe, the number of hospital beds in- Yellow fever has completely disappeared, and the creased from 1060 in 1952 to some 1300 in 1957, control of Aëdes aegypti is undertaken at the same and the number of beds in hospices rose from 150 to time as Anopheles control programmes. 250. A modern leprosy settlement with 80 beds was There is still a fairly large number of cases of leprosy; opened at the beginning of 1958 to replace the old excellent results have been obtained from systematic leprosarium on the Ile de la Désirade. A tuberculosis case- findingindispensaries and earlytreatment. sanatorium with 200 beds is to be built soon, and Many cases which were previously unknown have the mental diseases hospital, which has accommo- been detected at an early stage by this means, which dation for 400 patients,isbeing renovated and probably explains the comparatively high number extended.Several maternal and child health centres of known cases. were opened in 1956 and 1957, and others are being Tuberculosis is still very widespread, but systematic built. case -finding and the use of modern methods of Guiana has a total hospital bed capacity of 690, treatment are gradually bringing the incidence of this of which 210 are in hospices, and it has recently been disease into line with the average rates in other decided to build a new hospital in Cayenne to replace French departments. the two existing hospitals, which are in a bad state Yaws has been reduced to a few cases each year, of repair and inconveniently planned for modern and other infectious diseases do not present any needs.In every important locality there is a health particular problems. centre with a full -time physician in attendance, so The most difficult diseases to control, as in most that curative and preventive services are available tropical areas,are intestinal parasitic infestations, to the whole population, including the tribes of the which are extremely widespread and are one of the interior. chief causes of infant and child morbidity. In all three departments programmes of malaria Progress has been made in environmental sanitation control have been carried out systematically.Malaria since 1947. A large -scale programme of construction was entirely eradicated from Martinique by 1952, of water -supply systems has already been completed, and from Guadeloupe by 1955.In Guiana, cases and work is in progress on their extension to all the of malaria are now limited to the villages of the communes of these departments. Amazon forest, where preventive measures are still Large sewage -disposal schemes are being carried difficult to carry out among the tribes, and to imported out at Fort -de- France in Martinique, Pointe -à -Pitr cases among seasonal workers coming from neigh- in Guadeloupe, and Cayenne in Guiana; those o bouring countries. Fort -de- France and Cayenne are almost completed
GUATEMALA
Guatemala lies across Central America, immediately south of In local government, each department or province has a Mexico, and is divided by the Cordilleras into two unequal Governor appointed by the President; mayors of municipalities, drainage areas, of which the Atlantic is much the larger.The with their councils, are elected directly by the people. Pacific slope, however, is very well watered and fertile between The economy of Guatemala is based upon agriculture, coffee 300 and 1500 metres and is the most densely settled part of the being the principal crop.Bananas come next in importance. country.The Atlantic slope is sparsely populated and has little Sugar, rice, maize, beans and wheat are also produced, but of commercial importance, though there is timber, chicle, some mainly for home consumption.Guatemala is an important coffee and bananas.The area of the country is 108 889 square producer of chicle gum, citronella and lemon grass oils.Large kilometres. deposits of petroleum are also known to exist. The climate is warm and healthy, suffering little from the An illiteracy rate of 70.3 per cent. was shown in the 1950 humid and hot periods which prevail generally in Central census.Primary education (six years) is provided free of charge, America.The rainy season usually lasts from May until and is compulsory for children from the age of 7 to 12 years. October. The University of San Carlos, founded in 1678 and commonly At the 1950 census, there were 2 790 868 inhabitants, with a known as the University of Guatemala, is the sole university density of 29 per square kilometre, and in mid -1956 the popula- in the country.In 1910 it was reorganized to include faculties tion was estimated at 3 348 347.About 54 per cent. are pure of medicine, economics, law, engineering, social work, and other Indian from some twenty different language stocks; about subjects. 38 per cent. are ladino, or mixed Indian and Spanish stock, The main railway system is the United States -owned Inter- and the remainder are European.The annual rate of increase national Railways of Central America.There are 6900 kilo- in the total population was 1.16 per cent. between censuses. metres of highways (mostly unpaved), and two asphalted high- Twenty -five per cent. of the population are urban, living ways, one from Guatemala City to San José on the Pacific coast, mainly in Guatemala City (the capital) and in Quezaltenango, and the other to the tourist centre of Antigua, about 40 kilo- while the remaining 75 per cent. are distributed in small towns metres from the capital.Work is in progress on the Pan and communities. American Highway from Mexico southward, and the Atlantic 184 FIRST REPORT ON THE WORLD HEALTH SITUATION
Highway is under construction connecting the capital with maternity hospitals, four tuberculosis hospitals, one Puerto Barrios on the Atlantic coast.A government -owned mental hospital, and five other hospitals. airline is the sole means of transportation to some of the remote inland areas. The principal disease is malaria, which had a case rate per 100 000 of 929.6 in 1954, 737.0 in 1955, and 591.9 in 1956.Whooping -cough is also serious, with Health an incidence of 167.3 in 1956; and the case rate for The Ministry of Public Health and Social Assistance tuberculosis was 66.4 for the same year.The mor- includes two directorates -general, public health and bidity rate reported for syphilis has declined steadily social assistance, each headed by a director- general. from 52.8 in 1954 to 30.7 in 1956.Syphilis cases are The Directorate -General of Public Health has common in the coastal areas of the Atlantic, parti- services in the City of Guatemala and in the depart- cularly in the port of Puerto Barrios.Typhoid fever ments, including 29 health units and 12 sanitary morbidity rates reported for the three years 1954, offices, which are under the supervision of the units. 1955 and 1956 were 16.2, 22.0, and 15.0 respectively. The local health units in the 21 departmental capitals The main health programmes initiated in recent are each staffed with a doctor, a nurse, a sanitary years have concerned the training of nurses and the inspector and a laboratory technician.The services development of rural health services.In the first of rendered by these units consist of immunizations, these projects some religions establishments (such as control of communicable diseases, sanitary inspection that in Quezaltenango) have contributed materially. and health education.In most of the units laboratory The Franklin D. Roosevelt Hospital in Guatemala service is limited to microscopical examinations and City also has an ambitious programme of expansion parasitologicalinvestigations,withtheexception in this regard, as in social case work, but unfortuna- of five units where serological examinations are also tely these projects have been retarded by lack of carried out.There are health units also in the ports funds. of Ayutla -Ocos, Champerico, Livingston and San The Institute of Nutrition of Central America José.There are sanitary offices in six of the smaller and Panama (INCAP), which is well staffed and has towns, each with a nurse to perform routine immuniza- modern facilities, has for some ten years been carrying tions and to treat simple ailments.There are also out special studies in protein deficiency.The Guate- five mobile units, each with a doctor, a nurse and one malan Institute of Development has had some notable auxiliary worker, extending services to villages and successes in recent years in assisting the Indian popu- other remote areas. lation to cultivate other food crops, in addition to The municipal health service of Guatemala City corn and beans. maintains health centres which provide maternal and About 25 new doctors graduate annually from the child health care and other preventive services.They Medical School of the University of San Carlos. also give medical care to the needy sick. Admission to this school is based upon the secondary The birth rate was 51.5 in 1954 and 48.8 in 1955; school certificate (bachillerato), and the full course is for the same years the death rate was 18.4 and 20.6, and of eight years' duration, leading to the degree of the infant mortality rate was 87.9 and 101.4 respectively. Licenciado en Ciencias Médicas (Licentiate in Medical In 1957 there were in the country 542 doctors, Science).This degree entitles the holder to practise in 130 dentists, and 543 graduate nurses.Of these, Guatemala, no further examinations being required. 17 doctors, 30 dentists and 33 graduate nurses were Graduates frequently do post -graduate work in United employed by the government health services on a full - States institutions and hospitals.In 1956 this school time basis. had a teaching staff of 65, and an enrolment of 623 The country has 43 hospitals, with a total of 7874 male and 14 female students, with an entering class beds distributed among 31 general hospitals, two of 120.
HAITI
Haiti has an area of 27 750 square kilometres and occupies between summer and winter.The temperature in Port -au- the western third of the island of Santo Domingo, formerly His- Prince, the capital, rarely exceeds 35° C, but the humidity is paniola, the largest island of the Caribbean after Cuba.About high, especially in the autumn. two -thirds of the country consist of rugged mountains descending According to the 1950 census, the population was 3 097 304, steeply to the sea along most of the coast.Inland there are with a density of 112 per square kilometre.The estimated deep troughs between the ranges which form river valleys and population in 1957 was 3 383 762.The population is mainly interior plains.The climate is tropical, with little difference Negro, with many mulattos descended from the first French REGION OF THE AMERICAS 185
settlers, and about 2000 white settlers.French is the official urban health centres, five in Port -au- Prince and one language. each in Pétion -Ville, La Croix -des -Bouquets, Le Cap - Agriculture is the mainstay of the country's economy, and employs 1 453 900, or 87.8 per cent. of the total population. Haitien, and Les Cayes.The staff of this division Industry employs 85 400, and commerce 62 000. consists of 48 physicians, 20 dentists, eight pharma- Haiti has a wide variety of export commodities; the most cists, three sanitary engineers, 43 public health nurses, important is coffee, followed by sisal, rice, sugar, molasses and 30 hospitalnurses and midwives, 27laboratory rum.The cultivation of essentialoils, horse -breeding and technicians, 66 auxiliaries, 120 sanitary police officers, cattle -raising are being encouraged.Lumbering is dying out, particularly as far as mahogany is concerned, and mineral and 34 health inspectors. resources still remain undeveloped. The Assistant Director- General of the Division of At the 1950 census, 89.4 per cent. of the population over Rural Medicine supervises the organization and main- 10 years of age were illiterate.Women are eligible for all public tenance of establishments providing services in both offices from the age of 30 and may vote in municipal elections. Primary education is free, and is compulsory in urban areas. curative medicine and public health in the rural areas. Children enter primary school at the age of 6 or 7, and follow These establishments comprise seven large rural health either a five -, eight- or 10 -year course.Primary education in units (each with 20 hospital beds in addition to their rural schools is of six years' duration.The lycée, or secondary public health services), three health centres, 36 rural school, is open to pupils who have completed six years of dispensaries and 125 rural clinics.The division is primary education, and provides a further course of six years. The teaching of English has been compulsory in all schools staffed by: eight qualified physicians working on the since 1942. administrativestaff;43residentphysicians;six There are also national schools of agriculture, pharmacy, dentists; 10 nurses; 28 health officers and inspectors, obstetrics, and ethnology, and a polytechnic which is affiliated and 207 auxiliaries. to the new University of Haiti.Higher education is provided, free, at the Faculty of Medicine, the Faculty of Law, and the The national health services budget at the present Faculty of Dentistry ;there are also four law schools in the time is Gourdes 18 998 414.51 (US $3 799 683). provinces. The principal diseases in Haiti are malaria, intestinal parasitic infestations,gastro- enteritis(inchildren), Health tuberculosis, typhoid, syphilis and tropical ulcers. The Central Administration of the Public Health The incidence of yaws, which was more than 60 per Service is at the seat of the Government in Port -au- cent. in 1930, has decreased to less than 0.25 per cent. Prince and is in the charge of a Secretary of State for at the present time as the result of an eradication cam- Public Health, appointed by the President of the paign undertaken with theassistanceof WHO; Republic.He is assisted by a Director -General, who in 1957, during the course of a house -to -house cam- co- ordinates the activities of the three main divisions: paign, 6992 cases of yaws and 38 945 contacts were public assistance; public health, and rural medicine. treated.During the same year,300 008 persons Each of these divisions is headed by a physician with received smallpox vaccination with vaccine donated the status of Assistant Director -General. by Member governments of WHO. Tuberculosis The Assistant Director - General of the Division of control activities in 1956 included BCG vaccination Public Assistance is in charge of the organization and of 12 522 persons at eight clinic centres. maintenance of the urban hospitals of the country; Medical education in Haiti is of five years' duration, these consist of 11 general hospitals and six special excluding the pre- medical year.The fifth year of the hospitals, including three university units, with a course is devoted to internship, after which students total of 2137 beds.They are staffed by: 138 physi- receive the university degree of doctor of medicine. cians, 240 nurses (including midwives), 55 laboratory A licence to practise medicine,is, however, only technicians, 16 x -ray technicians, eight pharmacists, granted after a further two years' work in a rural area 16 anaesthetists and 135 auxiliary workers. or three years' specialization in one of the university The Assistant Director- General of the Division of hospitals of Haiti.The Faculty of Medicine and Public Health isresponsible for covering: epide- Pharmacy of the University of Haiti, which is a State miology; biostatistics; international quarantine; school school founded in 1830, has at present a teaching health and school dentalservices;environmental staff of 42 and a student body of 265.Furthermore, sanitation and sanitary engineering; control of phar- a Faculty of Dentistry provides a four -year course macies, drugs and narcotics; tuberculosis control; leading to the degree of dental surgeon.There are health visitor services; and the national public health also three schools of nursing, one in Port -au- Prince, laboratory.This Division is also in charge of three one in Le Cap - Haitien and one in Les Cayes. international co- operative units -the rural domiciliary The extension of water- supply systems in urban health unit, the national malaria eradication unit, areas is a matter which requires urgent attention.In and the Aëdes aegypti eradication unit -and of nine rural areas there is no public water -distribution system. 186 FIRST REPORT ON THE WORLD HEALTH SITUATION
HAWAII
Hawaii consists of a chain of islands and islets in the North In 1956 there were 130 health centres, both general Pacific,of volcanic formation, generally mountainous and and specifically for maternal and child health; 98 of rugged, and often covered in the interior with forest and vegeta- tion.The area is16 635 square kilometres.Seven of the them were in rural areas. islands are inhabited. Medical and health personnel in Hawaii in 1957 The territory of Hawaii is an incorporated organized territory included: 548 physicians, 397 dentists, 1861 graduate of the United States of America, and all persons born or nurses, 1585 other nurses, 10 midwives, 28 veterina- naturalized in the Territory are United States citizens.The estimated civilian population on 1July 1956 was 523 359. rians and 19 sanitary engineers.The following were Social customs follow those of the mainland United States, and employed full -time in the health service during the English has for some time been the main language. year: The territory is divided for administrative purposes into Provincial Local five counties -Hawaii, Maui, Kauai, Honolulu, Kalawao- (State) and the city of Honolulu. Physicians 10 4 Agriculture is of major importance, although less than 10 per Public health nurses 7 85 cent. of the total area is reasonably suitable for agricultural use; Other graduate nurses . - 2 more than half the arable land is devoted to sugar -cane, which Graduate engineers 4 2 is the main crop.The next most important items in the Sanitarians 4 85 territory's economy are pineapples and coffee, followed by the Other sanitation personnel 2 15 tourist trade and the fishing industry. Dentists 1 - Education is free and compulsory from 6 to 16 years of age, Dental hygienists 41 and the public school system comprises three categories: - Veterinarians 1 6 kindergarten; grades from one to twelve inclusive; and special. Laboratory personnel 1 20 The total enrolment in the schools of the territory was 106 464 in Health educators 4 1 1953 and 113 544 in 1954.The University of Hawaii includes Nutritionists 2 1 five colleges: Arts and Sciences, Applied Science, Teachers, Social workers 3 19 Agriculture, and Business Administration. Statisticians 3 -
Health Of the 3085 deaths registered in 1956, the chief causes were diseases of the heart (33.7 per cent.), The President of the Board of Health is the Chief cancer and other malignant neoplasms (16.5 per cent.), Executive Health Officer.The Department of Health vascular lesions affecting the central nervous system has six divisions: local health services; hospitals and (8.8 per cent.) and diseases of early infancy (8.2 per medical care; preventive medicine; dental health; cent.). sanitation; and leprosy.There areseveral other Measles is the most common communicable disease units in the Department, including health education in the territory; 6759 cases were reported in 1955 and health statistics.Sections in the Division of and 5848 cases in 1956.Tuberculosis is also a prob- Local Health Services supervise the health services in lem, the reported morbidity rate in 1956 being 110.1. the counties and in the city of Honolulu. In 1956 there were 34 centres and three mobile units The total expenditure on health for the year 1957 engaged in case -finding work.In the period under was US $4 613 101, including US $1 275 580 spent on review no cases of plague or smallpox were reported. local health services. In 1956 the total number of known cases of leprosy The Bureau of Health Statistics maintains a registra- was 459, and all the infectious cases were isolated; tion system for births, deaths, foetal deaths, marriages the non -infectious cases (133) were treated on an and divorces; the vital statistics for the years 1954, out -patient basis. 1955 and 1956 were: birth rate, 33.6,32.5, 32.7; Practically the whole of the population is provided death rate, 6.1, 6.2 and 5.9; and infant mortality with water -supply systems;18 connected systems rate, 22.4, 20.6 and 22.4. supply 344 900 people in urban areas, and 89 similar In 1957, 5016 beds were available in the 32 govern- systems supply 88 100 rural inhabitants, the remainder ment hospitals, which include 19 general hospitals of whom are served by private supplies.About half (1510 beds) one paediatric hospital (112 beds), one the population is served by a sewerage system, the maternity hospital (115 beds), four for tuberculosis remainder being served by private septic tanks and (1234 beds) and one mental hospital (1074 beds). latrines. REGION OF THE AMERICAS 187
HONDURAS
The Republic of Honduras is in Central America, lying epidemiology and school health, and laboratories. between 13° and 16° north and 83° and 89° west, and bordered Health units at the airport of Toncontin and at the by Guatemala, Nicaragua and El Salvador.The Caribbean coast is about 650 kilometres long and there is an outlet of ports of Ampala, Puerto Cortes, La Ceiba and Tela about 120 kilometres on the Pacific.The country is traversed are also part of the National Health Service, as are by the Cordilleras and is mountainous but with well- watered health centres at Choluteca and San Pedro Sula. fertile valleys and wooded tablelands. The area is 112 088 square The vital statistics for the years 1954 and 1955 are kilometres.The climate is tropical in the coastal belts and temperate and healthy in the hills. reported as follows: birth rate, 41.9 and 43.1; death The population at the 1950 census was 1 368 605 (with 72 385 rate, 11.2 and 11.4; infant mortality rate, 60.0 and 54.9. in the capital, Tegucigalpa), and on 1 July 1955 it was estimated In 1957 there were 18 general hospitals, with 3067 at1 659 934.Approximately 69 per cent. of the population beds, one maternity hospital, with 16 beds, and two are rural. tuberculosis hospitals, with 448 beds. The family systems, customs and cultural background are Latin American, but the indigenous population adheres to its The medical and health personnel in the country tribal traditions.According to a 1953 estimate, 63 per cent. in 1957 included: 365 doctors, 63 dentists, 103 graduate of the population over ten years of age were illiterate. nurses, 417 other nurses, and seven graduate midwives. The economy is agricultural, the chief products and exports The National Health Service employed on a full -time being bananas, coco -nuts, coffee and rice, in that order.There is an abundance of hard and soft woods, and mahogany and pine basis four doctors, three public health nurses, six other are exported.Production is mainly in the hands of private graduate nurses, three health educators, two sanitary enterprise, but most small farmers are tenants on government - engineers, one sanitarian, one laboratory technician, owned land. one dietitian, and one statistician.Furthermore, 171 Education is free and is compulsory from 8 to 15 years of age. doctors, five dentists, two public health nurses, 58 In 1953 the country had 24 elementary schools, 2316 primary schools, three secondary schools and six teacher- training schools. other graduate nurses, 417 auxiliary nurses, seven The National University at Tegucigalpa has faculties of law, graduate midwives, one sanitarian, one health educator medicine, pharmacy, economics and engineering, and in 1953 and 28 laboratory technicians were employed full - had 843 students. time in provincial and local health services. Travelling and transport are mostly by motor bus and lorries, but over a large part of the country the aeroplane is now the Malaria, helminthic infestations, gastro- enteritis and normal means of transport for passengers and freight.There other infectiousdiseases of thedigestive system, are 15 local airports and one international airport.Honduras whooping- cough, measles and tuberculosis appear to is connected with the highway system of Guatemala, Nicaragua be the most important communicable diseases. and El Salvador by the Pan American Highway; in 1952 there Efforts are at present being directed to combat were about 1980 kilometres of roads.In the north coastal region there are 1330 kilometres of railway. tuberculosis and to strengthen local health services. These latter are already provided to some extent in Health each of the 17 departments of the country.In some departments (Francisco Morazán, Atlántida) half the The Department of Public Health and Sanitation population is covered, whereas in others the percen- forms part of the Ministry of Health and Welfare, tage is much smaller.The services are under the and itsdivisions include :communicable diseases, supervision of doctors on a part -time basis, and maternal and child health, tuberculosis, hospitals, are staffed by sanitarians, laboratory personnel, and environmental sanitation, health education, nutrition, nurses where available.
JAMAICA
Jamaica -the most southerly of the Greater Antilles -lies Negroes, with mixed East Indian, European, Chinese and about 1600 kilometres north of the Panama Canal.With its Syrian groups following in order of size. dependencies -the Turks and Caicos Islands, the Cayman The economy is principally agricultural; the chief crops are Islands, the Morant Cays and the Pedro Cays -the total area sugar -cane, bananas, tobacco, coffee, pimento, citrus, rice and is12 113 square kilometres.There is a great diversity of maize.Bauxite and gypsum are mined. climate; the temperature ranges from between 26° C and 30° C The Industrial Development and Agricultural Development on the coast to less than 5° C in the mountains.The population Corporations were established in 1952.The first of these takes in 1957 was estimated at1 594 800; the great majority are part in new industries and encourages local investment by over- 188 FIRST REPORT ON THE WORLD HEALTH SITUATION seas investors.High priority is given to the production of rice. laboratory personnel and fourhealtheducators. In 1954, also, the International Bank for Reconstruction and Development submitted an economic plan for the territory A further 198 sanitarians and some 238 auxiliary involving an investment of £80 000 000 (US $224 000 000) within midwives are employed by the local health services. the next ten years; the present development programme is based The University College of the West Indies provides on this plan. a six -year course for medical students; the qualifying Primary education is provided free and is compulsory, gener- examination is that of the University of London. ally from the ages of 6 to 13.The secondary school course lasts for five or six years, and pupils are prepared for the School Nurses are trained at the Kingston Public Hospital Certificate and Higher School Certificate examinations of the and the University College Hospital in courses lasting Cambridge Syndicate, although some schools make use of the at least three years; reciprocal recognition is granted Oxford and Cambridge Joint Board Examinations and the by the General Nursing Council for England and School Examinations of London University, or the United Wales.Public health nurses must have general and Kingdom Certificate of Education for overseas pupils. The number of schools (and pupils) in 1954 were: primary, midwifery qualifications and must also have had 698 (218 000); secondary, 27 (8510); vocational, seven (2100); training leading to the Health Visitors Certificate of teacher- training, four (336); and higher education, one (384). the Royal Institute of Health (England), or comparable The University College of the West Indies is in Jamaica. training.Both the nursing and the public health Adult education is carried out by the Jamaica Social Welfare Commission, the Lands Department, the Bureau of Health nursing training are recognized as being of metro- Education, and the Sugar Industry Welfare Board.Existing politan standard. library facilities are the Institute of Jamaica, the West India Health visitors and sanitary inspectors are trained Reference Library, and the Science Library. at the West Indies School of Public Health in Jamaica, which serves the whole region.There are two types Health of training for sanitary inspectors, one leading to the certificate of the Royal Institute of Health and the Medical and public health services are headed by other to a local certificate. a Chief Medical Officer, with three Principal Medical There are 50 hospitals, including 26 government Officers, in charge respectively of health administration hospitals with out -patient departments, 134 dispen- and of the medical section, including hospitals and saries and health centres, 202 maternity and child personnel.The public health section has divisions, welfare centres, 15 tuberculosis control units (13 in with specialist officers in charge, for tuberculosis, hospitals or dispensaries), 10 venereal disease control venereal diseases and yaws, quarantine, health educa- units (seven in hospitals and dispensaries), one lepro- tion, malaria, maternal and child welfare, industrial sarium and one mental institution.The total bed health, and epidemiology. A Central Board of Health capacity of all hospitals is 6959, of which 2289 beds directs the work of local boards of health.Each of the are in the 21 general hospitals.During 1954, out- 14 parishes has its own local board of health, which patient facilities were increased by seven dispensaries, includes a public health department with a medical three health centres and two dental clinics.There officer,sanitary inspectors, and public health and are 24 private hospitals and nursing homes. districtnurses.The healthdepartmentsinthe Vital statistics for the years 1954 -57 were as follows : parishes attend to environmental sanitation, latrine 1954 1955 1956 1957 construction, mosquito control, inspection of water Birth rate 35.3 36.3 37.3 38.1 supplies and food, and personal hygiene. Death rate 10.7 9.9 9.5 9.08 In 1953/54, the allotment for public health was Infant mortality rate . . . 67.1 60.3 54.2 54.04 £196 000 (US $548 800) out of a total budget of £1 273 000 (US $3 564 400).In the following year, The morbidity rates per 100 000 population for public health received £320 000 (US $896 000) out of certain communicable diseases in 1954, 1955, 1956 a total of £1 653 000 (US $4 628 400). and 1957 were reported as follows: malaria, 288.3, Jamaica has 434 doctors, 92 dentists, 2125 graduate 217.7, 235.0, and 265.8; whooping- cough, 142.2, 18.5, nurses, 1034 graduate midwives, and two sanitary 80.6, and 16.5; tuberculosis, 47.9, 45.3, 38.7, and 43.9; engineers.Medical and health personnel employed and typhoid fever, 26.8, 29.7, 48.8, and 27.8 by the public health services are as follows : 172 doctors, In 1954 the main public health problems were 106 public health nurses, 954 other graduate nurses, malaria, pulmonary tuberculosis and yaws.The diet 26 graduate midwives, one graduate engineer, 99 of the Jamaican peasant is known to be deficient sanitarians,16 dentists, one dental hygienist,143 in protein. REGION OF THE AMERICAS 189
LEEWARD ISLANDS
The Leeward Islands lie in the Caribbean Sea, north of the Health Windward Islands and south -east of Puerto Rico.They consist of four separate islands or groups of islands- Antigua (with The Health Department of Antigua has three main Barbuda and Redonda), St Christopher (St Kitts)- Nevis -Anguilla, divisions :administration, hospitals, and district ser- Montserrat, and the British Virgin Islands.Until 1956 they vices. In1957itsbudget was BWI $970 855 formed a federation, with a federal executive council and a (US $571 091), of which BWI $496 824 (US $292 249) general legislative council, but under the Leeward Islands Act were for hospitals.In the same year, the health staff (1956) the federation was abolished and the federal executive and legislative councils were dissolved; the islands are now numbered 326, including 12 physicians (five of whom separate territories, with their own institutions and adminis- were full -time), nine public health nurses, 24 other trative machinery, although they unite for certain common graduate nurses, nine graduate midwives assisted by purposes, such as the Windward Islands and Leeward Islands 20 auxiliary midwives, 17 sanitarians, one veterinarian, Supreme Court and Court of Appeal.The normal residence of three laboratory workers, two dentists, three x -ray the Governor is in Antigua.Each of the islands or groups of technicians and five pharmacists. islands has its own administrator, with an executive council and In 1957 there were four hospitals in Antigua, a legislative council. including one general, one mental, one cottage hospital, and one leprosarium, as well as nine dispensaries, Antigua three maternal and child health centres, and three Antigua has an area of 443 square kilometres; the population venereal disease control centres.The public health in 1957 was estimated at 54 800.The capital, St Johns, has a centres assist in the distribution of food supplements, population of some 11 000. It is organized, as are the smaller as well as supplying public health nurses to advise and towns and villages, according to the British local government help families through home visits.Ili addition, there pattern, with community councils encouraged in the smaller are 28 nursing districts in Antigua and one in Barbuda; localities, as well as self -help projects from time to time. the district nurses assist in midwifery and treat minor The economy is almost entirely agricultural, and sugar and cases. A school dental service also exists but its cotton are the two principal industries and the main export development has been hampered by shortage of staff. crops.The seasonal incidence of work in the cotton and sugar plantations causes both under -employment and unemployment The birth rate in 1956 was 35.9, and the death rate on the island.Flour and grain, petroleum products, timber, was 9.3.The infant mortality rate was 50.1, the clothing and fish are the principal imports.As a result, the neonatal death rate was 19, and the foetal death trade balance in the last ten years has usually been negative, rate was 26.1. excessof importsoverexportsamountingin1954to The chief causes of death in 1956 were: diseases of BWI $4 682 000 (US $2 754 118).Such deficits are made good early infancy (56); arteriosclerosis (52); vascular lesions by the United Kingdom, which in that year granted £699 000 affecting the central nervous system (46); influenza and (US $1 957 200) under the Colonial Development and Welfare pneumonia (39);and gastritis and enteritis(37). Act. Among the principal diseases during the period under Pupils between the ages of 5 and 16 are admitted to all 36 of review, syphilis showed a steady decline -although its the government primary schools, where attendance is compul- sory (although this requirement was relaxed in 1954 owing to incidence still remains high -from 430 cases in 1954 overcrowding in two schools).Six government secondary to 279 cases in 1955 and 234 in 1956.The number schools (with 1273 pupils) charge low fees, but a number of free of reported cases of yaws has also drecreased from scholarships are available.Post -secondary education is pro- 70 in 1954 to 46 in 1955 and 27 in 1956.There vided by the Antigua Extra -Mural Department of the University were estimated to be some 50 cases of leprosy in College of the West Indies in Jamaica, and there is one private Antigua in 1956, of whom 32 were segregated.The teacher -trainingcollegewith10students(1954)on the number of reported cases of tuberculosis remained island. constant, at 19, 18 and 19 respectively during 1954, Adult education is organized by the Extra -Mural Department 1955 and 1956. of the University College of the West Indies, as well as by the There being no medical school, qualification is General Improvement Organization and the Antigua Trades usually obtained in the United Kingdom or in Jamaica. and Labour Union.Community councils, clubs and library services co- operate in this work. Nurses are also frequently trained in the United The housing shortage was relieved in 1954 by the Hurricane Kingdom, although in recent years more have been Re- housing Programme, under which 1348 new houses were trained locally in the general hospitals; the training built, and by the Slum Clearing project, which settled 151 fami- follows the syllabus of the General Nursing Council lies in new homes. for England and Wales.The midwifery course 190 FIRST REPORT ON THE WORLD HEALTH SITUATION follows the syllabus of the Central Midwives Board The death rate has gradually decreased in recent years; of England. the infant mortalityrate has fallenconsiderably In 1954 there were on the staff of the Sanitary since 1953, when it was 84.5. Service of Antigua 16 health inspectors who had The principal causes of death during the period received senior training at the West Indies School of under review were gastro- enteritis, avitaminosis, tuber- Public Health in Jamaica. culosis, syphilis, and dysentery.Among the most The sanitary service provides, inspects and clears serious public health problems are tuberculosis and latrines. malnutrition. A BCG vaccination campaign was In 1956 steps were being taken to provide the carried out in 1953 and 1954, and two tuberculosis island with a pipedinter -connected water -supply control centres have been established. system, which will serve the entire population, with Medical qualification is usually obtained in Jamaica the exception of some 2000 people in outlying farms or in the United Kingdom.Nurses are trained at the and houses. general hospitals, but senior training is normally taken in the United Kingdom.General nursing training follows the syllabus of the General Nursing Council St Christopher (St Kitts)- Nevis -Anguilla for England and Wales, and the midwifery course follows the syllabus of the Central Midwives Board of The three islands of St Christopher (St Kitts)- Nevis -Anguilla England.Dispensers are also trained at the general have a total land area of 396 square kilometres.The population in 1954 was estimated at 52 830, and in 1957 at 57 531. hospitals.Sanitary inspectors receive senior training The economy is almost entirely agricultural; sugar and cotton atthe West Indies School of Public Health in are the main export crops.St Kitts and Anguilla export salt. Jamaica. Development grants are administered by the Federal Govern- St Christopher- Nevis -Anguilla has no sewage -dis- ment from Colonial Development and Welfare funds. Primary education is free between the ages of 5 and 15 and posal system; of the 57 531 inhabitants in 1957, 4830 compulsory up to 13.Low fees are charged at government had private septic tanks, 27 790 had latrines, and secondary schools, and scholarships are provided for free 24 911 had neither. secondary education.Post -secondary education is provided by the Antigua Extra -Mural Department of the University College of the West Indies in Jamaica. British Virgin Islands The seasonal incidence of work in cotton- and sugar - growing (the two chief industries), is associated with both under- The British Virgin Islands have a total land area of 174 square employment and unemployment. kilometres; the estimated population in 1956 was 7760, of whom Community organization is based on the British local govern- about 87 per cent. lived in urban areas. ment pattern; community councils are encouraged in the villages, The economy is almost entirely agricultural; sugar and cotton and they undertake self -help projects from time to time. are the main crops.Livestock, fish and charcoal are also exported. Health Up to 1954, development grants to the British Virgin Islands under the Colonial Development and Welfare Act amounted There are three main divisionsinthe Health to £106 000 (US $296 800). Department: administration, hospitals, and district In 1954, the Virgin Islands had one government primary school and 15 private schools, with a total of 1886 pupils. services. There wasalsoone government secondaryschool,with The budget for medical and health services in 1957 113 pupils. was BWI $877 989 (US $516 464), of which the sum Most of the householders own, and usually build, their own of BWI $490 738 (US $288 669) was allocated for homes, which are strongly made of wood, stone or concrete as hospitals.The health services are staffed by 132 per- protection against the frequent hurricanes.Most of the people are self -employed small farmers, fishermen or traders. sonnel, including11physicians, 23 public health nurses, 34 other graduate nurses, 17 graduate mid- Health wives, 17 sanitarians and public health inspectors, two dentists, one veterinarian, and 20 clerical and There is a Medical Department, which provides other personnel. medical, health and sanitation services.The budget There are in the territory four hospitals, two urban for medical and health services in 1957 amounted to and 22 rural maternal and child health centres (serving BWI $45 457 (US $26 739).The health personnel of some 11 400 inhabitants), 22 dispensaries, eight ven- the British Virgin Islands in 1956 consisted of one ereal disease control centres, and one leprosy settle- doctor, three graduate nurses, and nine other nurses. ment with 18 patients. Between 1954 and 1956, the birth rate has remained In 1956 the birth rate was 44.1, the death rate at about 41, and the death rate at about 11.The was 11.0, and the infant mortality rate was 52.1. infant mortality rate in 1956 was 100.6. REGION OF THE AMERICAS 191
In 1956, there was one general hospital with 35 beds, Medical qualification is usually obtained in Jamaica six dispensaries, and four maternal and child health or in the United Kingdom.Nurses are trained at centres. the general hospital, but senior training is normally Syphilis, tuberculosis, and malnutrition are among taken inthe United Kingdom.General nursing the chief health problems; of 1749 serological tests for training follows the syllabus of the General Nursing syphilis made in1956,159 werepositive.The Council for England and Wales, and the midwifery number of reported cases of tuberculosis was 13 in course follows the syllabus of the Central Midwives 1954, four in 1955, and seven in 1956. Board of England.
MEXICO Mexico is in the southern part of the North American con- the main lines nationalized in 1937 and the British -owned tinent and has a wide seaboard on both the Atlantic and Pacific Mexican Railway Company, bought in 1946; and 36 airports Oceans. Two great mountain ranges of North America -the offer connexions with the principal international lines.The Sierra Nevada and the Rocky Mountains -extend from the north internal air service has 210 airports, and local services are into Mexico, where they converge towards the isthmus of provided by most of the larger states. Tehuantepec.The interior is an elevated plateau between these two ranges, with steep slopes to the two oceans.The climate varies with the altitude; the coastal lands below 900 metres are Health tropical; the plateau, from 900 to 2000 metres, is temperate. Above 2000 metres is the cold region, or tierra fia.The rainy The Secretary for Health and Welfare is a member season lasts from June to October.The country's area is of the Cabinet, responsible to the President of the 1 969 367 square kilometres. Republic.Under his control are the Directorates - At the 1950 census the population was 25 791 017, with a density of 15 per square kilometre.The annual rate of increase General for Epidemiology, Co- ordinated Services, in 1950 was 2.69 per cent.The most recent population estimate Sanitary Engineering, Social Welfare, and Administra- was 31 426 190.The 1950 census showed that 42.6 per cent. tion; and the Department of the Under -Secretary. of the people were urban and 57.4 per cent. rural. Directorates under the immediate supervision of Health and Social Affairs is one of the departments represented in the President's Cabinet. the Secretary for Health and Welfare include rural Each of the 29 states has its own constitution, government, medical services, nursing and social work, industrial taxes and laws; and its governor and legislature are popularly health, maternal and child welfare, health education, elected.The President appoints the governors of the terri- rehabilitation, vital statistics, control of foods, drug tories and the chief of the Federal District. control, social welfare, experimental public health The total arable land is estimated at about 243 000 square kilometres, of which only about 101 250 square kilometres are studies, and health and medical assistance in the arablewithoutartificialirrigation.Some 52 650square Federal District.Other services of this Department kilometres are under cultivation.Grazing land is estimated are the School of Public Health and Institute of at 324 000 square kilometres and there are about 202 500 square Tropical Diseases, the National Hygiene Institute, kilometres of forest.The basic crop is maize, of which the production in the last few years has been brought up to the level the Hospital for Nutritional Diseases, the National of consumption.Agriculturalexportsarecotton,sugar, HealthLaboratory,theLegalDepartment,the chickpeas, bananas, winter vegetables, coffee,sisal,linseed, Hospital of the Federation of State Employees, the fish and shrimps. General Hospital, the Juarez Hospital, the General The mineral wealth is very great: silver and gold, copper, Mental Hospital and the National Hospitals Com- lead, zinc, mercury, iron and petroleum are the main products. Between 1938 and 1942 the properties of foreign oil companies mission. wereappropriatedbytheGovernment.Indemnification Public health in the states is the joint responsibi- payments of US $8 600 000 were made annually from 1948 lity of the state governments and the Federal Govern- to 1954. ment.In1953thenationalhealthbudgetwas Six years of primary education are free to all irrespective of the age at which the pupil begins.There are 14 universities, of 186 000 000 pesos(US $21 502900) 1.Thestates which the National Independent University of Mexico, with 18 contributed inall another15000 000pesos(US faculties, is the most important as far as numbers of students $1 734 100), and the rural communities contributed are concerned.In all, 62 584 students graduated from this more than7 000 000 pesos(about US $810 000) University between 1940 and 1950; in 1952 it had 28864 students, towardstheco- operativerural medicalservices. of whom 4980 were women.There is also a University City. Mexico is well supplied with communications.There are Another source of income is through contributions 39 ocean ports, of which Veracruz and Tampico are the most from private individuals to the Public Welfare Fund. important.In 1956 there were 28 616 kilometres of roads, In one instance 100 000 000 pesos (US $11 560 694) of which 19 414 kilometres were paved, 6770 kilometres were asphalted, and 2432 kilometres were earthroads.There were also about 24 000 kilometres of railway line, including all 1 1953 exchange rate 192 FIRST REPORT ON THE WORLD HEALTH SITUATION
were also provided by the National Lotteryfor Graduate nurses amount to 2247, and 127 nurses the construction of the Mexico City Medical Centre. had special public health training.Other professional The vital statistics for 1953, 1954 and 1955 were: workers are: 2071 certified midwives; 491 veterin- birth rate, 45.0, 46.4 and 46.4; death rate, 15.9, 13.1 arians; 42 graduate public health engineers; 1601 and 13.7; infant mortality rate, 95.2, 80.5 and 83.3. dentists, and two dentists with public health training. There are 18 058 doctors for the entire country. The following persons were employed in the public Of these, about 375 are graduates in public health. health services in 1957:
National Provincial Local Category full -time others full-time others full -time other
Doctors 1 006 405 429 303 76 4 Public health nurses . . 1 812 707 58
Other graduate nurses. . 1 205 Graduate midwives . . . 51 45 13 Graduate engineers. . 18 4 15 9 2 Sanitarians 520 646 7 Dentists 3 36 7 43 3 4 Veterinarians 12 35 9 8 Laboratory personnel . . 536 10 103 5 10 Health educators. . . 2 10 Dietitians 2 Social workers 251 20 4 Statisticians 30 31 2 Secretariat personnel . . 2 682 615 66 Other personnel . . . . 4 366 254 1 237 25 109
Total 12 525 754 3 864 393 350 8
A corps of health officers has been formed, com- 1953 1954 1955 posed of 160 public health medical officers. Gastritis, enteritis, colitis, etc. 75763 59257 67563 Influenza and pneumonia . . 74704 52001 58328 In 1955 there were 448 hospitals in Mexico, with Certain diseases of early in- a total bed capacity of 31 719.Of these, 427 hospitals fancy 38974 40993 42218 wereforgeneralmedicine(includingmaternity Malaria 24596 19437 19639 hospitals) and had 26 466 beds; nine for tuberculosis, Heart diseases 22162 21565 22653 with 1069 beds; six for mental diseases, with 3584 beds; Accidents 13781 13949 14292 Bronchitis 10336 7996 8465 and six others, with 600 beds.The number of dis- Homicide 10805 10954 10782 pensaries for medical assistance increased from 207 Malignant tumours 8028 8333 8686 in 1953 to 391 in 1956. Measles 8709 4020 9716 There are 20 medical schools in Mexico, situated Avitaminosis 9470 7541 9037 inthefollowingcities:Campeche,Chihuahua, Tuberculosis 8608 8052 7708 Whooping -cough 9015 9519 7462 Durango, Guadalajara (2), León, Mérida, Mexico City(3),Monterrey,Morelia,Oaxaca, Pachuca, Puebla, San Luis Potosí, Tampico, Toluca, Torreón It will be seen from the foregoing table that malaria and Veracruz.Nine are owned and operated by is a serious problem in Mexico; it is estimated that the national Government, and the rest are privately 16 000 000 of the population are at risk, and a owned and operated by other organizations. A National Commission for Malaria Eradication has bachillerato, or secondary school diploma, admits been established to direct the widespread measures candidates for the six -year course leading to the being taken for the control and eventual eradication degree of Doctor of Medicine and Surgery:the of this disease from the country. An indication of curriculum includesa period of internship and the success of these measures so far is given by the compulsory practice in rural areas. decreasing number of cases during thelast few The principal causes of death and number of years: 50 947 in 1953; 48 521 in 1954; 41 169 in deaths during the years 1953 -55 were : 1955, and 33 360 in 1956. REGION OF THE AMERICAS 193
The number of primaryvaccinationsagainst ment with capacity for 450 patients.Twenty -four smallpox given in1956 amounted to1 639 232, dispensaries are in operation for ambulatory care of and that of re- vaccinations to 3 053 942.The local leprosy patients. production ofdriedvaccine was31 000doses, The number of poliomyelitis cases reported in 1956 and that of glycerinated vaccine was 12 068 630 reached 602, of which 557 occurred in children doses. under 5 years of age, 37 in the age -group 5 -9 years, Yellow fever vaccinations were given to 140 000 seven in the age -group 10 -14 years, and one in the persons in 1956 as compared with 13 365 between group 15 years and above. 1950 and 1953.Aëdes aegypti control was intensified In recent years emphasis has been laid on the at all the seaports, airports and frontier posts. programme for maternal and childhealth,rural The number of serological tests for syphilis made social welfare, health education, environmental sanita- in 1956 in government laboratories was 594 497, tion, rehabilitation and specific campaigns for the of which 188 481 were positive. control of communicable diseases.In 1954 there In 63 tuberculosis clinics and three mobile units, were 49 centres for rural social welfare; these have 212 487 x -ray examinations were made, which included since increased to 386, including all the federated 17 647 contacts.Diagnosed cases amounted to 5352 units, which benefit 3139 rural communities with and 637 among the contacts.The number of BCG an over -all population of 3 951 019. vaccinations reached 2064 in 1956. Special pre -natal and post -natal careisoffered The number of leprosy cases in 1956 was estimated in115 MCH centres; 939 general MCH centres to be 30 000 of which 13 408 were known; 650 of (458 in urban and 481 in rural areas) dealt with these were segregated.There is one leprosy settle- 2 095 209 patients in 1956.
NETHERLANDS ANTILLES
The Netherlands Antilles are situated in the Caribbean Sea, physicians, eight public health nurses, one other and comprise two groups 880 kilometres apart.The Leeward graduate nurse, nine auxiliaries, two graduate mid- group consists of the islands of Curaçao, Aruba and Bonaire, and the Windward group of St Maarten, St Eustatius and Saba. wives, one engineer, 17 sanitarians, 19 other sanitation The southern part of St Maarten, however, is French territory. personnel, and two veterinarians. The total area is 989 square kilometres, and the population was In the same year the territory had seven hospitals estimated on 31 December 1955 at 183 795, with 172 616 living (with approximately 1400 beds), including four general on Curaçao and Aruba -the principal islands, with areas of 443 square kilometres and 190 square kilometres respectively. hospitals, with about 880 beds, one tuberculosis The economy is based almost entirely on the refining of oil hospital, with 60 beds, one mental and one children's imported from Venezuela to Curaçao and Aruba.About hospital, with 400 and 55 beds respectively. 40 -70 per cent. of the gainfully occupied are working at the The proposed budget for health services for Curaçao refineries or their shipping establishments.In addition to oil and Aruba for 1957 was as follows: refining, Curaçao and Aruba rank high in shipping and trade. Bonaire and the three Windward islands are of relatively little NWI guilders * economic importance. Communicable diseases 65 000 Tuberculosis control 100 000 Health Venereal disease control 13 000 Industrial hygiene 185000 ** The operation of public health services has remained Local health services 258000 ** under the central Government, and an Inspectorate Maternal and child health 16900 ** Dental health (schools) 50000 of Public Health was created in January 1953 to Laboratory services 80000 ** promote health in general and to administer public Hospitals 589000 ** health regulations. Vitamins (Schools) 12000 ** In 1957 there were 126 physicians, 33 dentists, 172 NWI guilders 1.886 US $1.00 graduate nurses, about 400 other nurses, 29 graduate ** Curaçao only - data for Aruba not available midwives,twoveterinariansandsevensanitary engineers in the territory.Eight doctors, three nurses, The vital statistics for these two islands for the years 33 auxiliary nurses and 33 laboratory personnel serve 1954, 1955 and 1956 were reported as follows: birth in the central health services.The local health services rate, 32.0, 31.6, and 31.3; death rate, 4.6, 4.7, and 4.2; of Curaçao and Aruba employ in full-time service nine infant mortality rate, 21.0, 20.6, and 21.9.These 194 FIRST REPORT ON THE WORLD HEALTH SITUATION
figures, however, appear to cover only a limited area There are three tuberculosis clinics, where 3828 and cannot be regarded as representative. x -rayexaminationswerecarriedoutin1956, So far as communicable diseases are concerned, no revealing 36 cases.Suspected leprosy sufferers are cases of scarlet fever, smallpox, or malaria were reported,and examined by specialists;in1956, reportedduringtheperiodunderreview.For there were 23 known cases on the island, all segre- Curaçao and Aruba in 1956, 36 cases of tuberculosis gated.Smallpox and diphtheria vaccinationsare were reported, 24 of typhoid fever, four of diphtheria carried out, and yellow fever vaccinations (mainly and seven of leprosy.Twenty cases of poliomyelitis for the crews of ocean -goingtankers)arealso were reported in Curaçao. given.
NICARAGUA
Nicaragua is in Central America, with long coast lines on 1954 1955 1956 both the Atlantic and the Pacific Oceans; itis bounded by Birth rate 42.6 41.7 40.9 Honduras on the north and Costa Rica on the south.The Death rate 9.0 8.2 7.6 country is crossed by two mountain chains, separated by a Infant mortality rate . . . 70.8 66.9 63.5 depression in which there are two large lakes.The Caribbean, or Atlantic, coast is low and swampy; the Pacific coast is bold Provisional (incomplete) and rocky with some good harbours.The climate along the coasts is hot and often sultry but the uplands are cooler.The In 1957, there were in all 26 hospitals in Nicaragua wet season is from May or June to November or December. The area is about 148 000 square kilometres. with a total bed capacity of 2662; 23 of the hospitals The population at the 1950 census was 1 057 023, with a were for general medicine and included accommo- density of 8 per square kilometre.The annual rate of increase dation for paediatrics (192 beds), gynaecology and at that time was 2.37 per cent.In 1957 the estimated population obstetrics (173), and infectious diseases (63); one was was 1 331 322. Managua is the capital, with a population of about 110 000. reserved for tuberculosis (300 beds), one for mental The country is divided into 16 departments and one district, disorders (300 beds), and one for leprosy (68 beds). or Comarca. Medical and para- medical personnel in the country The country is mainly agricultural; its chief crops are coffee, in 1957 included: 464 doctors, 73 dentists, 225 graduate cotton, sesame, sugar, rice and maize.Livestock -breeding and nurses,182 other nurses,15 graduate midwives, timber production, already considerable, are capable of great expansion.Gold and silver are mined. 26 veterinarians, and two sanitary engineers.Of the Primary education is compulsory, free of charge, and consists above personnel, the national health service employed of a six -year course. in full -time service a physician, a public health nurse, and a laboratory technician.The part -timestaff Health (working from 7 a.m. to 1 p.m.) were composed of 22 physicians, 105 public health nurses, one dentist, The Minister of Public Health and a Vice -Minister 18 laboratory personnel, 24 health educators, 10 social are responsible for the following eight main divisions in workers, and one statistician. the health service :(a) administration, local health In the departmental (provincial) health services, another 17 dentists and units, and venereal disease prophylaxis; (b) epidemio- 58 laboratory peronnel were also employed on a part- logy and health statistics; (c) the National Institute of time basis. Hygiene; (d) the health inspectorate;(e)sanitary engineering; (f) health education; (g) tuberculosis The health budget for 1957 was allocated as follows : National Departmental control; and (h) insect control. (córdobas) ( córdobas) There are departmental health centres in the depart- Communicable diseases 82 120 ments of Jinotega, Chinandega, León, Masaya, Rivas, Tuberculosis control 380 100 Bluefields, Matagalpa, and Granada.Seven other Venereal disease control 114 200 departments have departmental health authorities, Malaria eradication 1241900 and health offices exist in San Juan del Sur, Puerto Environmental sanitation 1184450 - Mobile units 108000 Cabezas, and Somotillo.Diriamba and Corinto - Maternal and child health . 393840 - have departmental sanitary units. Dental hygiene - 49200 The birth, death and infant mortality rates have Nutrition 370500 - been gradually falling in recent years, and statistics Laboratory services 364860 296600 compiled for the years 1954 -56 are as follows: 7 córdobas = US $1.00 REGION OF THE AMERICAS 195
Syphilisistheprincipal communicable disease Maternal and child health services are provided notified in Nicaragua; in the years 1954, 1955 and in 24 centres.In 1956 these centres recorded 5350 1956 the numbers of reported cases per 100 000 pre -natalvisits,during which care was given to population were: 197.3, 171.3 and 156.8.In 1956, 3209 pregnant women, and 438 post -natalvisits. 37 973 serological tests were made, revealing 4527 In the same year, 8550 infants and children were positive cases, who received treatment: cared for by infant and child welfare clinics; 42 100 , Tuberculosis case rates per 100 000 during the three visits were paid by children to the clinics, and 959 years1954 -56 were :112.8,77.4, and 81.6.The visits were made to children in their homes. Ministry's Division for tuberculosis control maintains Nicaragua has one medical school - the Medical the tuberculosis hospital already mentioned, a mobile Faculty of the National University at León. A unit and an x -ray unit.Specialized staff at its disposal secondary school certificate is required for admission, consist of the medical officer in charge of the Division, and the course is of eight years' duration, including one medical specialist, one medical assistant, one one year of internship.The school was founded in laboratorytechnician,two graduatenurses,two 1814; in 1957 it had 45 members on the teaching x -ray technicians and one electrician.The social staff and a student body of 439. assistance centres in different parts of the country The water supply of Nicaragua in 1957 included co- operate in the work of tuberculosis control. 23 connected systems - 15 in urban and eight in The reported number of malaria cases per 100 000 ruralareas.The urban systemsserved168 206 population was 123.3 in 1954, 32.0 in 1955, and inhabitants, and of the remainder of the town dwellers, 14.3 in 1956.The incidence of typhoid fever has 38 000 had private supplies, 414 used public fountains, shown a marked decline during these years: 56.9, and 172 000 were not connected to a system of any 23.0, and 14.3.About 2000 cases of leprosy are kind.In rural areas, 4360 people were served by a estimated to exist in the country; in 1956, 100 cases piped system, 82 884 had private supplies and 67 936 were known, and of these 67 were isolated in a settle- people were not connected to a system. ment with a capacity of 68 beds.There is also one In the same year, there were six sewage - disposal diagnosis and treatment centrefor leprosyout- systems, all in urban areas, serving a population of patients. 62 803.
PANAMA
The country lies on the Isthmus of Panama, which connects A heavy international traffic runs through the Panama Canal North and South America.Its interior is rough and irregular, Zone ports of Cristóbal and Balboa. and there are mountain ranges in the west rising to over 3000 metres.Its area is 74 470 square kilometres, and the climate Health is tropical. The population at the 1950 census was 805 285 and the According to the reorganization plan of the Public estimated figure for 1957 was 911 100.According to the 1950 Health Services of 1956, the Minister of Public Health census, about 65 per cent. of the population are of mixed blood; 11 per cent. are white, 13 per cent. are Negro and 10 per cent is assisted by offices for liaison with inter -American are Indian. and international co- operative agencies, and isin The Republic of Panama is made up of nine provinces. charge of the Department of Public Health, of which The country is mainly agricultural with extremely fertile soil, the principal officer is the Director -General of Public although only about half is at present under cultivation.Bana- Health.Under the Director - General are the Director nas are the chief crop, but coco -nuts, cocoa, coffee and cereals are also grown to a large extent. A considerable amount of of Programmes for Hospitals and the Director of rice is raised for home consumption. A shrimping industry is Preventive Programmes.Of these two Directors, increasing in importance.In 1954 the value of per capita the first is responsible for hospital administration, production was reported to be US $250.All manufactured hospital nursing, the medical social welfare service goods and about 60 per cent. of the country's food requirements are imported.Much of the industry is owned by foreign and dietetic services.The second isin charge of interests. health education, health reports and studies, sanitary According to the 1950 census 28.3 per cent. of the population engineering, health centres (including public health over 10 years of age were illiterate.Elementary education is nursing, dental health, health inspection, and nutrition compulsory and free for all children from 7 to 15 years of age. The National University of Panama, founded in 1935, had programmes), and communicable diseases (including in 1951 -52 a total of 1778 students in law, science and other laboratories and pharmacies, veterinary work, and disciplines. tuberculosis and malaria control). 196 FIRST REPORT ON THE WORLD HEALTH SITUATION
In local administration, three Regional Directors, National Provincial for the Western, Central and Eastern Regions res- (balboas) (balboas) Total 1447 427 7 666 760 pectively, are responsible to the Director - General. Communicable diseases,including The Directors of the Western and Central regions both venereal disease control 29 220 9 680 have responsibility for regional and provincial hos- Tuberculosis control 2 200 157 100 Malaria control 499 782 - pitals, other regional and provincial health services, Environmental sanitation and regional and rural health centres.The Director 42 900 2 166 380 Vital and health statistics . . . 7 900 - for the Eastern Region has charge of the health services Localhealthservices,including in the cities of Colón and Panama, and of the health MCH and dental health . . 31 900 738 800 services and sanitary engineering in other parts of Nutrition 12 500 - his region. Laboratory services 56 180 - Hospitals 18 900 4 533 000 The birth rates for the years 1954, 1955 and 1956 Food and drug services 14 040 - were 39.5, 39.9 and 40.6 respectively.For the same Other 731905 61 800 years the general death rates were 9.0, 9.3 and 9.3, and the infant mortality rates were 52.6, 53.5 and 55.7 In 1956, 144 cases of poliomyelitis were recorded respectively. of which 121 occurred in children under 5 years of In 1956, there were in Panama 286 physicians, age, 13 in the 5 -9 age -group, three in the 10 -14 group, 80 dentists, 528 graduate nurses, 199 graduate mid- and seven in persons over 15.Vaccinations began wives,17 veterinarians and 12 sanitary engineers. in August 1956. The Department of Public Health employed at the On the basis of an estimated population figure of national level six physicians and 307 other personnel 886 000 in 1956, there was one physician for every (mostly administrative and clericalstaff), and for 3723 inhabitants in Panama. Added to this annually provincial services (mainly on a part -time basis) : are some 20 medical graduates from the country's 196 physicians, 95 public health nurses, 335 other one medical school in Panama City.This school is graduate nurses and 463 auxiliary nurses, 74 graduate government -owned and was founded in 1951 as a midwives and 29 auxiliaries, five graduate engineers, part of the University of Panama.In 1957 it had 176 sanitarians and 324 other sanitation personnel, a teaching staff of eight full -time and 42 part -time 43 dentists, two veterinarians, 23 laboratory technicians professors, and a student body of 54 males and 12 (excluding those employed in hospitals), eight health females.Students pay 112 balboas for tuition if educators, and 22 social workers. they are permanent residents of the country and There were 21 hospitals in the country in 1957, with 250 balboas if they are non -residents.The require- a total of 3552 beds.They included 12 general hos- ments for entrance are a four -year pre -medical course pitals, with 1880 beds (of which 172 were reserved at university level and a professional aptitude test. for paediatrics, 210 for gynaecology and obstetrics, The medical course lasts four years and leads to the and 89for infectiousdiseases), one tuberculosis degree of Doctor of Medicine. hospital, with 250 beds, one psychiatric hospital, Apart from the cities of Panama and Colón, piped with 792 beds, and seven private hospitals, with a water -supply systems serve 68 241 inhabitants in urban total of 630 beds. areas and 9961 in rural areas. The total health budget for 1957 was 9 114 187 For sewage disposal, 58 513 inhabitants of urban balboas.'This was distributed as follows : areas (not including Panama City and Colón) have private sewage pits, and 9980 have private latrines unconnected to a system.Of the rural population, 1 balboa = US $1.00 3774 have private sewage pits, and 29 412 have latrines.
PANAMA CANAL ZONE
In 1903 Panama granted to the United States of America in square kilometres.The total population on 1 July 1954 was perpetuity the use, occupation and control of a zone eight 38 953 exclusive of all uniformed army, navy and air force kilometres wide on each side of the Canal route and, within personnel; the 1950 census figure of 52 822 included that this zone, the exclusive right to exercise sovereign power and personnel. authority.The zone is governed by the Canal Zone Govern- ment. Health The area of the zone, including land and water, is 1432 square kilometres.The water area of the zone, including the water Medical and health services in the Panama Canal area within the limit from the Atlantic and Pacific ends, is 713 Zone are provided by the Canal Zone Government, REGION OF THE AMERICAS 197 and at the end of 1956 the following personnel were Of the 155 deaths recorded in 1956, 25 were from employed in these services : 96 physicians, one engineer, heart disease, 18 from cancer, 18 from diseases peculiar four public health nurses, 207 other graduate nurses, to early infancy, 15 from vascular lesions affecting sevendentists,sixsanitarians,88othersanitary the central nervous system, 14 from accidents and personnel, four veterinarians, 44 laboratory personnel six from tuberculosis. and seven nutritionists.The services of four doctors The incidence of communicable diseases seems to and eight public health nurses are also available on have decreased during theperiod under review. a part -time basis. In 1954 and 1956, the numbers of reported cases A health director is in charge of the public health of those principally occurring were: syphilis, 55 and services, which include hospitals and clinics, and divi- 34; tuberculosis, 23 and 27; measles, 61 and 25. sions of sanitation, veterinary medicine, and preventive No cases of plague, leprosy, yaws, smallpox, yellow medicine and quarantine. fever or typhus were reported. There are four hospitals in the Zone, with a total Altogether15 202serologicaltestsforsyphilis of 940 beds.Two are general hospitals with 520 beds, were carried out in1956, revealing 1887 positive one is a mental hospital with 300 beds, and there is cases;tuberculosis case -findingiscarried out in one leprosarium with 120 beds. two clinics, where 9149 x -rays were made in 1956, The operating budget for the health services for and 28 new cases were found.In the same year the fiscal year 1957 totalled US $5 999 100, of which 295 BCG vaccinations and 22 re- vaccinations were US $5 557 100 were allocated to hospitals and the given.Vaccination was carried out against smallpox remainder to the public health services. (2568primary),diphtheria,whooping -cough and The vital statistics for the years 1954 -56 are as tetanus (4075 children were vaccinated). follows : There were 16 cases of poliomyelitis in the Canal Zone in 1956, nine of them in children under five 1954 1955 1956 years of age.Three iron lungs are available and there is also a rehabilitation centre for polio patients. Birth rate 31.7 31.4 30.4 Death rate 6.8 4.5 4.2 Vaccination is carried out, and 21 640 ml of vaccine Infant mortality rate . . . 23.5 24.5 26.5 were administered in 1956.
PARAGUAY
The Republic of Paraguay is one of the two inland countries Standing Committee for Co- ordination and a Bureau of South America, the other being Bolivia, which borders it of International Health Relations.The Directorate on the north -west; Argentina lies to the south -west, and Brazil to the east.The area of Paraguay is 406 752 square kilometres has three main departments: (1) the Administrative and the population at the 1950 census, including the estimated Department; (2) the Department of Normative Ser- population of Guarani jungle Indians, was 1 408 000-a density vices, comprising (a) the division of technical services, of four per square kilometre.The rural population, which with sections for maternal and child health, epidemio- forms 65.4 per cent. of the total, earns its livelihood by cattle - breeding -the principal occupation.Few of the peasants en- logy and zoonoses, venereal diseases, tuberculosis, gaged in farming own their lands, large estates being the rule. nutrition, mental health and dentistry; (b) the division Yerba maté is exported, as well as meat, quebracho tanning of general services, with sections for health education, extract, sugar, cotton, timber and hides.Mineral wealth is health statistics, professional education, nursing and abundant but only slightly exploited.Because the importation control of medical practice; and (e) the division of of foodstuffs is a heavy drain on the national budget, the Govern- ment is encouraging greater production of wheat, rice and environmental sanitation (created in 1955), with sec- groundnuts. tions for sanitary engineering, industrial hygiene, Education is free and compulsory, but not available in all control of rodents and insect vectors, control of para- areas, and the latest revision of the school system includes, sitic diseases, and food control; and (3) the Depart- inter alia, primary education for adults.In 1953 the National University at Asunción, the capital, enrolled about 2043 students. ment of Executive Services, comprising (a) a division A contributory insurance plan for all workers (except civil of local health services, with branches in each of the servants) came into effect in 1951. Departments of the Republic; (b) a division of social welfare; and (c) a division responsible for the health Health services of the capital, with sections for out -patient The General Health Directorate has a Minister of and hospital services, pharmacy and laboratory ser- Health and Social Welfare, who isassisted by a vices. 198 FIRST REPORT ON THE WORLD HEALTH SITUATION
At the end of 1956 the following personnel were ment and support of patients suffering from this employed in the health services of Paraguay: disease.
Full -time Part -time In 1956, there were 1679 known cases of leprosy, 375 of them segregated; the number of cases in the Doctors 72 145 Public health nurses 17 country is, however, estimated at 4787 and an intensive Other graduate nurses 79 campaign against this disease was started towards the Auxiliaries 146 432 end of 1955.One leprosy settlement can accommo- Graduate midwives 163 date 400 patients, and there are also eight out -patient 4 Sanitary engineers clinics. Sanitarians 22 Dentists 1 52 The maternal and child health programme is ex- Dental hygienists 4 panding, and in 1956 there were 47 health centres Veterinarians 1 providing maternal and child health services and serv- Health educators 9 ing a total population of 909 000.In the seven urban centres, 3250 women attended for pre -natal attention There were 857 doctors in the country, as well as during 1956, and 4700 pre -natal and 1700 post -natal 271 dentists, 88 trained nurses and 579 other nurses. attendances were recorded. Two thousand visits were Medical care facilities are available in 130 hospitals, made to children at home and 12 000 visits were made with a total of 3588 beds -78 general (2287 beds), by children to the centres.The 40 rural centres, 38 paediatric (301 beds), eight maternity (200 beds), serving a population of 759 000, provided pre -natal two for infectious diseases (40 beds), two for tuber- care for 25 006 women; 32 100 pre -natal and 32 100 culosis (360 beds) and one for mental disorders post -natal attendances were recorded. A total of (400 beds). 56 500 children received care through 70 000 clinic Communicable disease control services in 1956 in- visits and 1500 home visits. cluded 159 435 primary vaccinations against smallpox, In 1956 a programme of rural health was initiated, with 62 376 revaccinations.Attention has been given and plans were made to increase the sources of potable to tuberculosis, and 80 730 x -ray examinations were water, to provide adequate sewerage facilities,to made in 1956, revealing 301 cases.Since 1945, a maintain certain standards of sanitation in schools, compulsory insurance plan has provided for the treat- and to encourage habits of personal hygiene.
PERU
Peru is on the Pacific coast of South America, between Ecua- Agriculture and mining are the principal industries and employ dor and Chile.It is traversed throughout its length by the over 70 per cent. of the population.The chief crops -in order Andes, which run parallel to the coast and rise to peaks of of value -are cotton, potatoes and other vegetables, sugar- over 7000 metres.There are three main regions: the coast, cane, fruit, maize, rice, wheat, barley, grapes and coffee.The west of the Andes; the Sierra, or mountain ranges of the Andes, minerals produced in 1953 were lead, zinc, copper, iron ore, including the lonely and barren mountains below the region petroleum, silver, gold, tungsten, bismuth and vanadium (Peru of perpetual snow; and the selva, which is the vast area of is the world's largest producer of vanadium).The islands off jungle stretching from the eastern foothills to the eastern fron- the Pacific coast provide guano, a valuable fertilizer, which is tier.Lima, the capital, is in the coastal area, which is cooled exported.The country is short of machinery, foodstuffs, and by the Humboldt Current and is not tropical.The total area pharmaceutical products, and there has been a trend in recent is 1 249 049 square kilometres. years to produce some of these goods locally; development The estimated population in 1953 was 8 591 300, consisting loans to this end were obtained in 1955 from the International of about 3 283 000 whites or mestizos, 2 847 000 Indians, 29 000 Bank for Reconstruction and Development.In 1954 the Negroes and 4200 Asians.The population of Lima was estim- per capita production was valued at US $120.Government ated at 1 005 000 in 1954; other large towns are Callao (112 400), monopolies exist for the import, local manufacture and sale of Arequipa (106 000), Cuzco (61 500), and Trujillo (53 000). guano, tobacco, salt, matches, alcohol, explosives, and playing The culture of Peru is Spanish in the urban areas; in the rural cards. areas, particularly in the mountains, Indian customs prevail. Primary education is compulsory and free between the ages The President isassisted by a Cabinet of 12 members, of 7 and 14.Secondary education has also been free since am ong whom is the Minister of Public Health and Social 1946 and is provided for pupils from 12 to 17 years of age. Welfare. The chief port is Callao, which clears over 12 million tons Since 1953 the 23 departments of the country have been of shipping annually.There are 3760 kilometres of standard divided into 139 provinces and 1350 districts; the province of gauge railways; a good modern network of paved highways Callao has some of the functions of a department.Each connects the remote cities with the coast; and an international department is administered by a prefect and each province by air service connects Lima with all the other South American a sub -prefect. republics. REGION OF THE AMERICAS 199
Health forest areas of Loreto, where 4243 vaccinations were given in 1954 and where only one case was reported The Minister of Public Health and Social Welfare up to 15 August.The inspection of 81 633 houses in is in charge of the health services, and within the 1956 revealed no positive foci of infestation of Aëdes MinistrytheDirectorate -Generalof Healthhas aegypti. fiveDepartments:(1)Department of Technical Bubonic plague is no longer a problem in urban Guidance Services, with divisions for sanitary en- areas, although it is still serious in certain ruçal areas gineering, communicable diseases and epidemiology, at altitudes of 1000 -2000 metres, particularly in places tuberculosis,maternalandchildhealth,school along the Ecuadorean frontier, where there is abundant health, leprosy, dental health, hospitals and preventive vegetation.In 1954, three cases were reported in services,socialwelfare,biostatistics,andhealth Piura, 14 in Lambayeque, 30 in Cajamarca, and six education; (2) Department of Health Areas, with in Ancash. divisions for organization of services, supervision and The decline of malaria in the coastal area is illus- co- ordination, social assistance, and maintenance of trated by the results of a survey made among the services; (3) Department of Pharmacy, with divisions school population between 5 and 14 years of age. for pharmaceutical laboratory production, supervision Inall,26 544 schoolchildren were examined, and of laboratories, pharmacies and druggists, and control the malaria parasite rate was found to be 0.79 per of medicaments and public medicaments distribution cent. services; (4) Department of Nutrition, with a division Triatoma infestans has been found in some of the for school meals; (5) Department of Administration, southern departments along the Chilean frontier as with divisions for administration, finance, budget and far as the 14th parallel and from sea level up to 3000 budgetary statistics, accounts, and personnel matters. metres.Since 1952, when insect control measures The Directorate - Generalof Healthisdirectly began, 262 432 houses have been treated in an area responsible for the following units :(a)Office of of 64 759 628 square metres, and 1 230 333 inhabitants Planning, Co- ordination and Evaluation; (b) Office have been protected. for International Relations; (c) Office of International For the control of tuberculosis, there were in 1954 Health; (d) National Institute of Health; (e) Institute four mobile x -ray units, 14 tuberculosis control centres, of Nutrition; (f) Institute of Occupational Health; special wards for child and adult tuberculosis patients and (g) Institute of Neoplastic Diseases. in some of the hospitals, regional sanatoria, and The Directorate - General of the National Health some preventoria for children.The " Social Action " and Social Welfare Fund co- ordinates its work with serviceensuresthatpatientsandtheirfamilies thatof theDirectorate -General of Health,and receive economic support, and the Social Security approves special allocations of funds for the develop- Officehas a fund forspecialassistance.There ment of certain health programmes. were altogether 3579 beds reserved for tuberculosis In 1954, the birth rate was 34.3, the death rate patients in 1954, but itis planned to increase this was 10.9, and the infant mortality rate was 94.4. number to at least 7029.In the south, an 800 -bed Since1950,a systematic nation -wide smallpox regionalsanatoriumisunderconstruction,and vaccination campaign has been in operation, and no similar plans are being made for the north and caseof smallpox has been reported since1954. north -west. Typhus is endemic in the Andean region, and in 1950 Leprosy is most prevalent in the north -east of Peru the Government initiated a control programme in - particularly in the departments of Apurimac and certain areas of the departments of Cuzco, Puno, Loreto - where some 80 per cent. of all the cases Arequipa and Tacna, bordering on Bolivia and Chile. in the country are found.There were 958 recorded Later, stock " E " of Rickettsia prowaseki in a live cases in this area in 1954, while the total number vaccine was developed and tested in Peru in co- opera- in the area was estimated at 2800 and the over -all tion with Tulane University in the United States of incidence at between 12 and 15 per 1000 inhabitants. America.As a result, only three cases of typhus In the country as a whole there were 1117 known cases, (with no deaths) were reported in 1953 in the area 3400 estimated, and a general incidence of 0.40 per treated in Cuzco department, compared with 581 cases 1000.The leprosy control service is staffed by ten and 66 deaths in 1948. doctors and two social workers. Yellow fever has been practically eliminated; it is Maternal and child health services are provided now found (and to a very limited extent) only in the in 92 centres in different parts of the country. 200 FIRST REPORT ON THE WORLD HEALTH SITUATION
PUERTO RICO
Puerto Rico is an island of the Greater Antilles group, lying 1954 1955 1956 between 18° and 19° north and 66° and 67° west, with a total Birth rate 35.0 35.0 34.1 land area of 8897 square kilometres.It is about 161 kilometres Death rate 7.6 7.2 7.3 from west to east and 64 kilometres from north to south at the Infant mortality rate 57.8 55.1 55.5 western end, narrowing towards the eastern extremity. At the 1950 census, the total population was 2 210 703, with Hospital facilities are provided in 129 hospitals, 224 767 in the capital, San Juan; in 1955 the population was with a total of 12 283 beds - i.e., approximately 1 bed estimated at 2 264 000.The majority of the inhabitants are of Spanish descent, and Spanish is the official language.In 1955 per 176 inhabitants; these include 116 general hospitals 18.5 per cent. of the population over 10 years of age were (7049 beds); eight tuberculosis hospitals (2760 beds), illiterate. three mental hospitals with 2234 beds, and two other Trade is carried on principally with the United States of hospitals (240 beds). America, which received 96 per cent. of the island's exports in 1955 -mainly sugar, tobacco leaf, rum, fibre textiles and There are 217 health centres, 90 of them in urban manufactures.Ninety per cent. of the imports came from the and 127 in rural areas, providing maternal and child United States.Sweet potatoes and yams are also cultivated in health services, and covering a total population of the island.There are salt works, small deposits of high quality 2 211 000 people. In 1956, 43 299 expectant mothers marble, and fair -sized deposits of white china clay. received pre -natal care and 30 296 children were Education is compulsory.The University of Puerto Rico in Rio Piedras is open to both men and women, as is also the cared for by these centres. San German Polytechnic Institute.In 1955 -56, the University Medical and health personnel in Puerto Rico had 11 947 students, including 2025 extramural students. in1957 included:1612 physicians;325 dentists; In mid -1956 there were 6900 kilometres of paved roads and 1912 graduate nurses; 1823 other nurses (licensed 759 kilometres of railways on the island. practical nurses); 23 graduate midwives; 1072 auxiliary midwives; 61veterinarians; 20 sanitary engineers. Health The personnel employed full -time in the health services were as follows : The Department of Health, headed by the Secretary National * Local ** full -time others for Health, is administered in four main divisions - full -time others Physicians 213 84 180 69 hospitals, public health, social welfare and administra- Public health nurses . 327 tion.The division of public health has units dealing Other graduate nurses 511 227 - with the control of communicable diseases, venereal Auxiliaries 801 848 - diseases, tuberculosis, control of malaria and insects, Graduate midwives 22 Auxiliary midwives 5 public health laboratories, maternal and child health, Sanitarian 32 handicapped children's services, dental health, public Other sanitation personnel 237 health nursing, and sanitation.The local health Dentists 6 40 3 services in each of the 33 districts of the country are Dental hygienists 2 also supervised by the Division of Public Health, Veterinarians 1 Laboratory personnel . 150 47 1 and include 20 health centres, 56 health units, and Health educators . . . 25
129 sub -units.Units for health education, mental Nutritionists or dietitians 48 13 health,medicalsocial work,nutrition,statistics, Social workers 47 10 hospital construction, cancer control and medical Statisticians 12 Clerical personnel 1 111 105 - education are also attached to the central services of Other personnel 2 857 1 212 1 the Department of Health. Local health services have been well developed * National includes all personnel employed by the Department of Health of the Commonwealth of Puerto Rico at State and local level for preventive in each of the 33 districts of Puerto Rico, and cover and curative services, excluding vacant positions. ** Local includes all personnel employed by municipal governments for environmentalsanitation,communicablediseases, curative services. maternal and child health, medical care, statistics, laboratory services and health education. Of the total of 16 243 deaths reported in 1955, The total expenditure for health services in 1957 2244 were reported to be due to diseases of the heart; was US $25 931 028 including US $6 929 376 from 1709 to gastritis and enteritis; 1592 to malignant municipal authorities for medical care, the rest coming neoplasms; 1433 to diseases peculiar to early infancy; from the Commonwealth Government of Puerto Rico. 905 to influenza and pneumonia; 903 to vascular The main vital statistics for the years 1954 -56 were lesions affecting the central nervous system; 743 to as follows : tuberculosis; and 630 to accidents. REGION OF THE AMERICAS 201
The incidence of communicable diseases has shown are served by public taps or fountains, and 791 000 in a considerable reduction in the period under review. rural areas have other sources of supply. The reported case rates for the following diseases per So far as sewage disposal is concerned, 64 systems 100 000 population for 1954 and 1956 were :tuber- - allin urban areas - serve 433 000 people.In culosis, 201.1 and 143.9 ;syphilis,125.8 and 69.8; urban areas, also, 40 000 are served by private septic whooping- cough, 111.3 and 24.9. tanks and 35 000 by latrines.In the rural areas, In 1956, 300 000 x -ray examinations for tuberculosis 30 000 are served by private septic tanks and 759 500 were made at 20 clinic centres and by three mobile by latrines. units, revealing 1276 cases.Of 158 148 serological A pilot project is at present being carried out by tests for syphilis 8819 showed positive results.Thir- the Department of Health of the Commonwealth teen cases of malaria were reported in 1954, seven in of Puerto Rico in the Bayamon General District 1955 and none in 1956.Of the 150 known cases of Hospital area, to demonstrate the proper integration leprosy, 96 are segregated in the country's one lepro- of preventive and curative medical services with sarium. public welfare services in the area.The findings from There are 217 health centres doing maternal and this project will determine the feasibility of extending child health work, 90 in urban and 127 in rural the programme to other areas. areas; in 1956 they provided pre -natal services for The University of Puerto Rico School of Medicine, 43 299 expectant mothers and infant care for 30 296 which was founded in 1949 and is owned and operated children. by the Government, has an annual enrolment of about Nearly all the population is served by a water - 52, and some 43 students graduate each year.In the supply system; the dwellings of 965 000 people are academic year 1955 -56, there were 279 students in connected to the 166 systems; 454 000 inhabitants the school.
SURINAM
Surinam, previously known as Dutch Guiana, lies on the A new building is now being prepared to accommodate north coast of the South American continent between latitudes and centralize most of the divisions of the Bureau. 1° 50' and 6° 7' north and longitudes 53° 59' and 58° 2' west. It is bounded on the north by the Atlantic Ocean, on the east At the end of 1953 there were 100 physicians in by French Guiana, on the west by British Guiana, and on the Surinam, and by 1958 this number had increased to south by Brazil.The area is 142 822 square kilometres. 137, of whom some 55 per cent. were in government The registered population at the end of 1953 was 219 436, service, and 28 per cent. were medical specialists. and there were an estimated 22 000 Bush Negroes and 3700 aboriginal Indians living in the forests.The capital, Parama- The majority are settled in the capital. ribo, had a population of 96 951 at the end of 1955.At the Vital statistics in 1957 were as follows : birth rate, end of 1957 the total population of the territory was estimated 39.5; death rate, 11.2; and infant mortality rate, 53.0. at some 270 000. Tuberculosis mortality, which was 72 per 100 000 For administrative purposes Surinam is divided into seven inhabitants in 1940, had fallen to 19 in 1953 and 16 districts.The territory is under the authority of a Governor. Agriculture is restricted to some areas of the alluvial coastal in 1957. A mass BCG immunization campaign was zone, and about 29 000 hectares are under cultivation.The carried out in 1955 and 1956 with international assis- staple food crop is rice.The chief products are sugar, cocoa, tance and included nearly 108 000 Mantoux tests and coffee, paddy, maize, bananas, rum, molasses, citrus fruits, 55 521 BCG vaccinations. tubers and coco -nuts.The principal exports are rice, citrus fruits, coffee, coco -nuts, balata, bauxite and timber. The government leprosarium has been modernized, In 1956 there were 159 public and private schools, with a and owing to modern methods of treatment the total of 45 000 pupils.There are also 36 schools for Indians number of patients in the three leprosaria of the and Bush Negroes run by missions. territory fell from 509 to 268 between 1954 and 1958. There are about 400 kilometres of main roads in the territory, chiefly in the vicinity of Paramaribo and the settlements along A school for children suffering from tuberculoid the rivers. A railway links Paramaribo to Kabelstation.There leprosy and for suspect cases, which had been function- is an airport, at which several international airlines call. ing since 1931, was closed in mid -1958, as only six children were registered. Health Malaria is holoendemic in the interior and hyper- The Bureau of Public Health was established in 1944, endemic in some parts of the savannah region.In with a staff of four.By 1953 the number of staff had the coastal zone, however, the number of new cases increased to about 250, and by 1958 to some 350. has declined from 13 788 in 1931 to 769 in 1953 and 202 FIRST REPORT ON THE WORLD HEALTH SITUATION
288 in 1957. A campaign for malaria eradication an endemic area in 1957 revealed that, of 3772 persons was started in 1957 with international assistance ; examined, 374 (9.9 per cent.) had S. mansoni eggs in key personnel have been trained, and geographical their faeces, and of 3980 persons examined, skin and epidemiological reconnaissance has been com- tests were positive in 536 cases (13.5 per cent.).With pleted.Total- coverage spraying began in 1958 and the development of road construction in the coastal is planned to continue until 1961. area, it is feared that bilharziasis will become one of No epidemic of urban yellow fever has occurred in the most serious problems in the territory. Surinam since 1909, but jungle yellow fever is prevalent Three mobile medical teams were organized by in the savannah region and in the interior, where the Government in 1956 to work in the interior, and in Haemagogus species and monkeys are present. A the same year a new hospital under a religious mission programme fortheeradication of Aëdes aegypti was opened, also in the interior.The Public Health with international assistanceisbeing planned in Division of the Surinam -American Technical Co- conjunction with the malaria eradication campaign. operative Service started operating at the beginning of Control measures in urban areas are carried out 1955; health demonstration programmes are being asa matter of routine, but resistance of Aëdes organized in rural areas, and personnel to staff the aegypti to insecticides has been encountered in the health services are being trained both in Surinam and capital. abroad. A large modern health centre was established Mass treatment of filariasis was started in 1949. by the Service in 1958 at Lelydorp. In a survey of 50 000 inhabitants of Paramaribo With assistance from UNICEF, a programme of between 1949 and 1951, Microfilariae bancrofti were milk distribution isin progress for the benefit of found in 17.4 per cent. of the people examined; expectant and nursing mothers, pre- school children, after mass treatment a second survey of 45 000 people schoolchildren and others.Free school lunches are was made between 1954 and 1956, revealing an provided for some 2500 children from needy families. infection rate of 6.1 per cent. Partial malnutrition is found among many people Yaws control on a large scale has been carried out in the lower income groups. in Surinam for many years; the disease is, however, The supply of drinking -water for the capital became still prevalent in rural areas, especially among the rather short as a result of many new houses being Indians and Bush Negroes. built in the suburbs.To meet this situation, a new Bilharziasis due to Schistosoma mansoni is endemic filtration plant has been installed.Water supplies in the coastal swamp areas where there are shell in rural areas are being improved with the help of the ridges, and is particularly prevalent among the Indians International Cooperation Administration. who are rice farmers.The disease is not found in New legislation on housing came into force in 1957, the savannah region and in the interior, where the laying down standards for new buildings and guarding intermediate snail host is absent. A survey made in against over -building in the capital.
TRINIDAD AND TOBAGO
The islands of Trinidad and Tobago lie at the southern end nations of the University of London, or in subjects of topical of the Lesser Antilles and close to the coast of Venezuela and interest. the Orinoco delta.The climate is tropical, with an average A Planning and Housing Commission was set up in 1940 and rainfall of 2.5 -7.5 centimetres a month from January to May, by 1956 had provided apartment buildings in Port -of -Spain and and 17.5 -25 centimetres a month from June to December.The San Fernando for 682 families, and 1493 cottages in semi -urban area of Trinidad is 4828 square kilometres, with a population and rural areas.The expenditure up to the end of 1956 was estimated in 1956 at 742 500.The area of Tobago is 300 square BWI $10 000 000 (US $5 882 353).The Sugar Industry Labour kilometres. Welfare Fund has provided three housing settlements, with a Trinidad is an agricultural country with substantial deposits total of 200 building lots for owner- occupation. A field scheme of crude petroleum, which provide its principal exports together on aided self -help principles was completed in 1954, and by 1956 with asphalt, sugar, cocoa, and rum. one group of 15 houses had been completed and other projects Education is compulsory for all children between 6 and were being launched. 12 years of age who live within two miles of a school.Technical The Extension Service of the Education Department is trying subjects are taught in 12 centres by the Board of Industrial to stimulate social progress by informal adult education, to foster Training, and theExtra -Mural Department oftheUni- self -help and mutual help and to assist voluntary agencies in versityCollege of the West Indies provides a variety of community development.In 1956 there were 1244 groups and eveningclasses,incoursesleadingtodegreeexami- village councils with a membership of 42 690. REGION OF THE AMERICAS 203
Health centres; 912 health centres and dispensaries; four tuberculosis centres, two in dispensaries and two The Minister of Health isresponsible for the separate; 15 venereal disease control centres, of which policy of the Health Department, the services of which 13 were in dispensaries, one in a general hospital and are administered by the Director of Medical Services, one separate; one leprosarium and nine specialized assisted by two deputy directors and a technical dispensaries; and two mobile units, one for dentistry staff.A Central Board of Health of nine members and one for x -ray. appointed by the Governor, of which the Medical Medical and health personnel on the island include: Director is Chairman, is authorized to make regula- 235 doctors, 85 dentists, 1039 graduate nurses and tions and has general powers of supervision and 462 other nurses, 982 graduate midwives, and 14 veter- control.Theterritoryisdividedintosanitary inarians. districts under local health authorities. The health services consist of 147 doctors (of Municipal health authorities exist in the capital, whom 39 are part- time), 91 public health nurses and Port -of- Spain, and in San Fernando and Arima. 1039 other graduate nurses, 81 sanitarians, 22 dentists, Local health authorities have also been set up else- eight veterinarians (seven full -time), 56 laboratory where. personnel, one health educator, two nutritionists, The essential vital statistics in 1954, 1955 and 1956 seven social workers, and 113clerical personnel, were as follows: birth rate,41.9, 41.9 and 36.9; as well as some 600 other workers. death rate, 9.8, 10.3, and 9.6; and infant mortality Hookworm infestation, venereal diseases and tuber- rate, 60.5, 67.9, and 63.9. culosis are the most prevalent diseases.Malaria is In 1956, there were 18 hospitals with a total of declining; its rate per 100 000 has decreased from 3751beds, including four general hospitals, with 790.6 in 1954 and 213.6 in 1955 to 21.0 in 1956. 1176 beds; three tuberculosis hospitals, with 484 beds; Nine cases of poliomyelitis were reported in 1956: one mental hospital, with 1032 beds, and 10 other three in children under five years of age; four in hospitals, with 1059 beds.Seven of the last men- children between five and nine years; and two in the tioned are district hospitals, with about 249 beds. 10 -14 age -group.The island has two rehabilitation In addition, there were 159 maternal and child health centres.
UNITED STATES OF AMERICA
The United States of America occupies most of the southern There are 48 states and the Federal District of Columbia, part of the North American Continent, bounded by Canada on which includes Washington, the seat of Government.Each the north and Mexico on the south.The physical features are state has its own constitution.Within the state, the chief unit varied.From the Atlantic coastal plain, the Appalachian range of local government is the county, of which there are over 3000. rises at about 250 kilometres from the sea and falls on the west The economy of the United States is industrial and agricultural, to the great Mississippi- Missouri Valley.Thence there is a both on a large scale.About 61 per cent. of the total land gradual rise though prairie country to the Rocky Mountains, surface consists of farms.There has been a great increase in the which fall again to valleys separated from the Pacific by the farm output owing to a higher degree of mechanization, greater coastal ranges of California, Oregon and Washington. use of lime and fertilizer, improved varieties of plants, and more The climate is also varied.On the east coast it ranges from effective control of insects and disease.Some of the recent maritime through semi -continental to humid -temperate; in the gains have been obtained by decreasing the soil fertility reserve. centre, from prairie- steppe to semi -arid; and on the west coast The United States has a very large iron and steel industry. from maritime to Mediterranean.There are some deserts in Precious metals are mined mainly in nine western states.There the western Rocky Mountains area, such as those of Arizona, are a good number of large hydro -electric plants, often combined New Mexico and Idaho. with irrigation schemes and community water supplies. The area of the United States is 7 827 976 square kilometres, Each state of the Union has a system of free public schools and its population was estimated at 170 148 000 in 1957, with established by law.Every state also has compulsory school a density of 21 per square kilometre.Between the 1940 and attendance laws which generally cover the years from 7 to 16. the 1950 censuses, the anual rate of increase was 1.36 per cent. Nearly three- quarters of the children stay in school until the According to the 1950 census, 64 per cent. of the population age of 17. are urban and 36 per cent. rural. In 1957, there were 1890 universities, colleges and professional The general educational level is high and there is practically no schools with over three million degree- credit students.The illiteracy.The main occupations are agriculture, employing leading fields of study for the master's degree were education, seven million; mining, one million; manufacturing, 17 million; engineering, business and commerce.At the doctorate level, and commerce, 11 million. the most popular were education, chemistry and psychology. 204 FIRST REPORT ON THE WORLD HEALTH SITUATION
Health primarily, with transforming knowledge into practice. It establishes uniformity in registration of mortality, The Public Health Service of the United States had morbidity, and vital statistics.On a national scale, its origin in an act of 1798, authorizing medical and it helps states, industries, civic groups, and other hospital care for American merchant seamen.Sub- federal agencies to identify and solve health problems sequent legislation has vastly broadened its activities, through basic and applied research, training and tech- especially in the past two decades.In 1939, the nical consultation in such subjects as heart disease, Service was transferred from the Treasury to the cancer, tuberculosis, venereal diseases, water supply Federal Security Agency, and in 1953 a further re- and water pollution, sewage and industrial waste organization plan transformed that Agency into the disposal, milk and food sanitation.At the same time, Department of Health, Education, and Welfare. it is intensifying its efforts against some of the more The Public Health Service is administered by the important health problems of today, such as accidents, Surgeon General, under the supervision and direction chronic disease, aging, radiation, and air pollution. of the Secretary of Health, Education, and Welfare. It assumes responsibility for emergency public health The Public Health Service is the Federal Agency services, especially in case of natural disasters, co- specifically charged with the following functions : operating with states in developing national pro- (a) to conduct and support research and training in grammes against communicablediseasesthrough the medical and related sciences and in public health direct aid in epidemics and disasters,continuing methods and administration; (b) to provide medical field studies on the epidemiology of diseases, labora- and hospital services to persons authorized to receive tory investigations, development of materials and care from the Service, to aid in the development of methods of disease control, consultations and demons- the Nation's hospital and related facilities and to trations,andtrainingpublichealthpersonnel. prevent the introduction of communicable diseases It conducts, or advises on, Public Health Service into the United States and its possessions; and (c) to responsibilities regarding international health agencies assist the states, other governments, and professional and programmes. and voluntary groups in the application of new The National Institutes of Health (NIH) form the knowledge for the prevention and control of disease, research arm of the Service.Their object is to extend environment, and the basic knowledge in all problems of health and sickness. improvement of human health. The Institutes have made notable contributions to the The Office of the Surgeon General is responsible study of such conditions as cancer, diseases of the for administrative and management activities within heart and circulation,allergy,infectiousdiseases, the Service. rheumatism,metabolicdisorders,dentaldiseases, The Bureau of Medical Services administers hospital mental health problems and many neurological con- and out -patient care for federal beneficiaries, and also ditions.The Institutes conduct research in their own quarantine and the medical examination of immigrants. laboratories and, through research grants, aid medical It is responsible for the health programme for Ameri- science throughout the United States and in foreign can Indians and the indigenous population of Alaska. countries.The Institutes are also concerned with the It provides technical assistance to states in survey, regulationofbiologicalproducts.TheClinical planning and the construction of non -profit hospitals, Centre is a research institution.It was especially diagnostic and treatment centres, rehabilitation centres designedtoco- ordinateclinicalandlaboratory and nursing homes.The Bureau administers the research with the aim of securing improved diagnosis, research programme on hospital services and gives treatment and cure of diseases, especially in the long- grants -in -aid to states, hospitals and universities for term group. NIH also supports training for research research in this area.Its officers give technical advice through fellowships and training grants.Its post- and provide personnel for health programmes of other doctoral research fellowships have been extended to Federal Agencies. include citizens of foreign countries. The Bureau of State Services operates the federal - There are many other agencies in the United States stateand inter -statehealth programmes, and is concerned with health in the broad sense, and it concerned with international healthactivities.It would not be possible to describe or even to enumerate administers grants for health services and provides them in detail.Perhaps the most remarkable develop- technical assistance to states and local health depart- ment among the older agencies was the Children's ments.It awards public health traineeships to pro- Bureau, which was attached to the Department of fessional health personnel to improve the competence Labor from 1913 to 1939, when it was transferred to of state and local health workers.It is concerned, the Federal Security Agency.This Department has REGION OF THE AMERICAS 205 conducted investigations and made reports on all At 1 January 1956, the total health personnel in matters related to child life.It has been faithful the country included:218 000 physicians,89 000 to its aim of increasing opportunities for the full dentists, 430 000 graduate nurses and 400 000 other development of all children in the United States by nurses, 5000 sanitary engineers, 18 000 veterinarians, promotingtheirhealth andsocialwelfare.The 500 graduate midwives and 9000 auxiliary midwives. Children's Bureau has issued a long series of both In 1956, the total number of physicians employed technical and popular publications.It co- operates in national health services was 13 518; in state health with the national, state and local organizations, giving services,456; and in local health services1488. grants to state agencies for mothers and children, and For the same year, the total number of public health in particular it has set out to improve all the special nurses employed in the government services was, services for children, especially the handicapped group. at national level,13 500; at state level, 829; and Vocational rehabilitation has received special atten- at local level, 12 900.The total number of sanitary tion at the federal level; it has taken a great part in personnelemployedinthenational,provincial the development of schemes for preserving or restoring and local health services in 1956 was about 9975 the ability of disabled men and women to perform (1628 graduate engineers and 8347 sanitarians and useful work.These schemes are organized in co- other sanitary personnel).In the same year, about operation with states.Both physical and mental 6000dentists,some 7500 graduatenurses,2075 rehabilitation and standards of service have been veterinarians, approximately 700 laboratory techni- applied. cians and some 33 000 auxiliaries were employed The total expenditure for hospitals from federal at the national level.The total laboratory personnel and state government budgets in 1955 amounted employed in government services at all three levels to US $1 589 153 000, of which US $836 769 000 were numbered 3526. federal expenditures.The total government expen- There are 85 medical schools in the country, with diture for local health services in 1956 was US a total of about 6845 medical graduates annually. $177 187 224, with US $127 163 949 from local, US The total number of hospitals in the country $40 232 633 fromstate,and US $9 790 642 from reported in January 1956 was 6956 and the number of federal sources.The total expenditure on tubercu- hospital beds was 1 604 408, distributed as follows: losis control, not including sanitoria costs, from all Hospitals Beds the state governments in 1956 was US $24 222 805, General 5 578 696 326 and federal expenditure was US $4 517 806.In 1956 Other general services: thetotal sum spent by the state governments on Paediatrics 54 6 296 venereal disease control was US $14 015 297, not Maternity 78 3 448 including US $1 185 305 from federal appropriations Infectious diseases 20 2 632 Tuberculosis 374 80 505 for the same purpose. Mental 586 772 852 For the years 1955 and 1956, the following rates Others 266 42 349 - based on registered events - were reported:
1955 1956 The voluntary hospitals are chiefly general hospitals Birth rate 24.6 24.9 where patients are usually under treatment for short - Death rate 9.3 9.4 term conditions. Infant mortality rate 26.4 The turnover in mental and tuberculosis hospitals Neonatal death rate (0 -28 days) 19.1 is so low that these units, with more than half of the beds, account for only 3 per cent. of the admissions. The chief causes of death reported for 1955 were as Two -thirds of the beds in state and local government follows : hospitals are for mental patients, who generally spend Number of deaths a long period in hospital. Diseases of the heart 584620 As in so many other countries, mental illness has Malignant neoplasms, etc 240681 created very serious problems in hospital accommoda- Vascular lesions affecting the central ner- vous system 174142 tion.Most of the hospital care is provided in state Accidents 93443 or federal tax -supported institutions and thestate Certain diseases of early infancy (760 -776) 64043 governments bear the heaviest burden in providing care Influenza and pneumonia 44510 for the mentally sick.There is increasing evidence General arteriosclerosis 32486 that closer co- operation among these hospitals and a Diabetes mellitus 25488 Congenital malformations 20502 study of the possibility of increased home care would Cirrhosis of liver 16763 reduce substantially the number of beds in operation. 206 FIRST REPORT ON THE WORLD HEALTH SITUATION
The main responsibility for providing health services (2)The effort of the individual himself is a vitally rests with state and local health authorities.In each important factor in attaining and maintaining health. of the 48 states there is a State Health Department (3)The doctor /patient relationship isso funda- with provision for all branches of health services, mental to health that everyone should have a personal including environmental sanitation.The local health physician. services consist of city or municipal health depart- ments and county health departments, with their (4)The physician should have access to proper field provisions to render direct health service to the facilities and equipment, affiliation on some basis with a hospital, and the help of trained personnel in population.The general principles on which the health services are founded lay due stress on public order to fulfil his part in providing comprehensive responsibilities for the provision of hospital and me- health services. dical care, without detracting from the importance of (5)Comprehensivehealthserviceincludesthe individual effort.The health of the people depends positive promotion of health,the prevention of primarily on the willingness of the individual to seek disease, the diagnosis and treatment of disease, the rehabilitation disabled - all medical care in the early stages of illness.Never- of the supported by theless, society must ensure for its citizens reasonable constantly improving education of personnel and a continuous programme of research. access to professional services, including the provision of health education and a safe and healthy physical (6)Comprehensive health service is the concern environment.In a highly complex modern com- of society and is best ensured when all elements of munity, many of the environmental services have society participate in providing it. passed far beyond individual control. (7)Responsibility for health is a joint one, with The following numbers of cases were reported in the individual citizen and local, state and federal 1957for some of theimportant communicable governments each having major contributionsto diseases :measles, 486 799; scarlet fever and strepto- make towards its fuller realization. coccal sore throat, 226 973; syphilis and its sequelae, (8) The American peopledesireanddeserve 136 039; all forms of tuberculosis, 86 861; whooping - comprehensive health service of the highest quality cough, 28 295, and poliomyelitis (both paralytic and and in our dynamic expanding economy, the means non -paralytic), 5485. can be found to provide it. To summarize, in the words of the President's (9) The same high quality of health services should Commission on the Health Needs of the Nation, the be available to all people, equally. following principles may be regarded as established (10) A health programme must take into account in the United States : the progress and experience of the past, and the (1)Access to the means for the attainment and realities of the present and must be flexible enough preservation of health is a basic human right. to cope with future changes.
URUGUAY
Uruguay lies on the eastern bank of the Rio de la Plata, sunflower seed and rice are cultivated.Meat exports in 1952 and has land boundaries with Argentina and Brazil and a sea amounted to 175 975 metric tons; the wool crop was 88 600 met- coast on the Atlantic.The country consists mainly of undu- ric tons, and 251 165 bales were exported.Machinery, motor lating grassy plains, with a few ranges of hills not exceeding vehicles, hardware, yarns and chemicals, fuel and lubricants 650 metres.The two main rivers are navigable.The climate are imported. is reasonably healthy and the temperature is uniform, with Primary education is compulsory, and both primary and higher some cold spells in the winter.Rainfall is regular throughout education are free.The University of the Republic at Monte- the year, but there are occasional droughts.The areais video, which was inaugurated in 1849, has 10 faculties. 186 926 square kilometres. Several railway companies were brought under a single ad- The last census was in1908, when the population was ministration in 1952; the total length open for traffic is 2880 kilo- 1 042 686; in 1956 it was estimated at 2 614 775.Approximately metres.There is a notable mercantile marine including many one million people live in the city of Montevideo, the capital. river vessels.The airport is served by nine different European The population is almost entirely of European (predominantly and American airlines. Spanish and Italian) descent. The country is divided into 19 departments, each with a chief Health of police and a mayor. The economy is mainly pastoral: there are large herds of The Ministry of Public Health hasfive main cattle and flocks of sheep.Wheat, barley, maize, linseed, divisions: the Division of Hygiene, the Technical REGION OF THE AMERICAS 207
Division, the Division of Assistance, the Pharmacy culosis and gastro- enteritis.According to the number Division, and the Division of Administration.The of cases reported, measles, whooping- cough, tuber- Division of Hygiene is divided into a number of culosis, typhoid fever, syphilis and poliomyelitis are sectionsdealing withstatistics,health education, important among the communicable diseases. occupational health, and environmental health, and Forty -two cases of smallpox were notified in 1956, it also administers clinics and laboratories for venereal and in the same year 56 788 persons were vaccinated diseasescontrol.TheDivisionof Assistanceis against this disease, and 39 847 were revaccinated. in charge of 63 hospitals, 17 departmental centres, Eighty -six cases of poliomyelitis were reported in 27 auxiliary centres and 133 rural polyclinics.It 1954, 551 in 1955, and 71 in 1956; 32 656 persons also supervises the health services in the capital, received the first dose of poliomyelitis vaccine and which include hospitals and polyclinics.In addition 24 559 received the second during1956.In the to the Ministry of Public Health, other official agencies same year, 48 222 children were vaccinated against and semi -official institutions carry out certain public diphtheria and 26 130 against whooping- cough.The health work.Emphasis is laid on the curative rather number of leprosy patients in the country is estimated than on the preventive side; all services are free. at1200, about 75 of whom are segregated in a In 1957, medical and para- medical personnel in settlement.The Aëdes aegypti eradication campaign the country included : 3116 physicians, 1650 dentists, was expected to be completed by the beginning of 1958. 420 graduate nurses, 834 graduate midwives, 191 Tuberculosis control work is carried out by 34 veterinarians, and seven sanitary engineers.As in clinics and eight mobile teams.Mass x -ray examina- other Latin American countries part -time personnel tions totalled 128 856 in 1956, revealing 665 active are employed to a very great extent in all the govern- cases, and 34 344 BCG vaccinations were performed. ment services.In the 62 government hospitals in In 1956 there were seven maternal and child health the country the number of beds totalled13 750, centres in the country, serving a total population - 3850 of which were for mental patients, and 2115 were exclusively urban - of approximately 300 000.In for tuberculosis. the same year, 17 620 women received pre -natal care, The general death rates and infant and maternal and 28 105infantsand children were attended; mortality rates are relatively low, although in rural according to clinic records, 22 705 visits were paid areas they are not so favourable.The death rate to children in their homes, and 15 452 visits were paid in 1953 was estimated at 7.7, in 1954 at 7.4, and in by children to infant and child welfare clinics. 1955 at 7.9.The birth rate was 18.7 in 1953 and 19.3 A total of 206 water -supply systems served about in 1954.Infant mortality rates were 51.2 in 1953, 75 per cent. of the population in 1956;1 350 000 and 49.3 in 1954.Maternal death rates were 1.8 in people had a piped supply, and 300 000 were served both 1953 and 1954. by public fountains. The main causes of death in 1956 were malignant In the same year, there were 25 sewage -disposal neoplasms, cardiovascular diseases, diseases of early systems, to which the dwellings of about 44.9 per cent. infancy, accidents, influenza and pneumonia, tuber- of the population were connected.
VENEZUELA
Venezuela is the most northerly of the South American re- The area is 912 050 square kilometres.The population at publics; it is bounded on the north by the Caribbean Sea, on the the last census, in 1950, was 5 034 838, with a density of 6 per west by Colombia, on the south by Brazil, and on the east by square kilometre.The estimated population in mid -1956 was British Guiana.There are about 70 islands off the coast.The 5 772 790.The 1950 census omitted tribal Indians, estimated Eastern Andes cross the border from the south -west and extend at 56 700.In1950, 53.8 per cent. of the population was to the Caribbean.On the Brazilian border, other ranges send urban. off parallel northward spurs, between which there are the valleys Venezuela is a republic, with a President.There are 20 states, of the Orinoco and its tributaries.The slopes of the mountains two territories and a federal district.The cabinet includes a and foothills are wooded, whereas the basin of the Orinoco is Minister of Health and Social Assistance.The 20 states, mainly level stretches of open prairie with occasional woods. which are politically equal, have each a legislative assembly The Orinoco is the principal river and is navigable by large and a Governor.They are divided into 156 districts and steamers for about 1100 kilometres from its mouth. 624 municipalities, while the federal districtis divided into The climate is tropical and unfavourable except where it is two departments and 22 municipalities.Each district has a modified by altitude or tempered by sea breezes.The hot wet municipal council, and each municipality a communal junta. season lasts from April to October, the dry cooler season from Petroleum provides the principal industry: Venezuela is the November to March. largest petroleum exporter in the world and the second largest 208 FIRST REPORT ON THE WORLD HEALTH SITUATION
producer.Other industries are small, but agriculture, stock - of public health.The construction of water supplies raising, dairy- farming and forestry are important. and sewage -disposal plants in towns is the responsibility Principal exports,in addition to petroleum, are coffee, diamonds, gold, and cocoa.Iron ore is growing in importance. of the National Institute of Sanitary Works, which is Principal imports are machinery, textiles, foodstuffs, steel and autonomous but on whose administrative council the iron, and chemicals. Minister of Health and Social Assistance is represen- Elementary education is free and compulsory from the age ted.The construction of rural water -supply systems of seven.During the school year 1955 -56 there were: 6956 prim- is being carried out under a co- operative programme ary schools with 623 083 pupils; 224 secondary schools with 40 556 pupils; 82 special schools with 13 973 pupils, and 43 implemented jointly by the Ministry of Health and teacher -training schools with 5133 students.There are three Social Welfare, thestategovernments,andthe State universities, in Caracas, Mérida and Maracaibo, and two Government of the United States of America. private universities in Caracas; the total student body in the The recorded death rates in 1954, 1955 and 1956 academic year 1955 -56 was 7791. The chief ports are La Guaira, Maracaibo and Puerto Cabello. were 10.3, 10.4 and 10.3; the birth rates were 47.6, In 1952, the Government, with the consent of the oil companies, 48.2 and 48.1; infant mortality rates were 68.4, 69.9 proposed to establish a fleet of oil tankers.There are 13 main and 66.7, and maternal death rates were 1.5,1.4, railway lines (1000 kilometres) and 19 927 kilometres of roads and 1.4.The main causes of death during the period which are fit for traffic all the year round.There is an important under review were gastro- enteritis, international air service; the national airline has a subsidiary heart diseases, for international traffic. diseases of early infancy, malignant neoplasms, in- fluenza and pneumonia, accidents and tuberculosis. Numerically the most important communicable dis- Health eases reported were measles, whooping- cough, syphilis, The principal technical sub -division of the Ministry tuberculosis, malaria and typhoid fever. of Health and Social Welfare is the Directorate of The medical and para- medical personnel in Vene- Public Health, which consists of the following Depart- zuela in 1957 included: 3689 physicians, 632 dentists, ments :Demography and Epidemiology, Environ- 2027 graduate nurses, 5020 other nurses, 990 auxiliary mental Sanitation (with divisions of sanitary engineer- midwives, 170 veterinarians, and 34 sanitary engineers. ing, malaria, yellow fever and plague, and veterinary There were 268 hospitals with a total of 21 406 beds; public health), Adult Health (with divisions for tuber- 233 of these were general hospitals, with 14 420 beds; culosis, leprosy, cancer, cardiovascular diseases and the specialized hospitals included 17 for tuberculosis, venereal diseases), Local Services (health units and with 2883 beds, and 16 for mental disorders, with hospitals, health centres and rural medical posts), a total of 3103 beds.There were 57 health units Maternal and Child Health (with divisions for maternal and centres in the country, serving an urban popula- and child health, school health and dental hygiene), tion of 2 758 453 and a rural population of 454 872. Mental Health, Social Welfare, the National Institute In addition, there were 393 medical posts, serving of Hygiene, General Secretariat (divisions for health a population of 1 970 191, of whom 875 956 lived education and pharmacy and sections for international in towns. organizations, food control -registro de alimentos- As regardsspecialpublichealth programmes, and personneladministration),and aTechnical vigilance is maintained in the control of yellow fever. Advisory Service (administrative management and Twenty -nine cases of yellow fever were notified in 1954, budget, planning, and technical advice). five in 1955 and three in 1956.Inoculations against The National Nutrition Institute, the Venezuelan the disease are being continued; 491 332 persons were Council forChildren,theInstituteof Scientific inoculated in 1956, and it is stated that more than Research, the national organizations for school meals 80 per cent. of the population at risk has now been and for the care of the aged and disabled, and the inoculated.One hundred and forty -seven centres National School of Nursing are autonomous institu- carry out viscerotomy.Plague is enzootic in a certain tions which are part of the Ministry's central organiza- zone and efforts are being made to prevent it from tion.At the present time plans are under considera- spreading to other parts of the country.Thirteen tion for the establishment of a Directorate of Social cases of smallpox were reported in 1954, two in 1955, Affairs. and four in 1956; 638 844 persons were vaccinated In the health field the states and municipalities are against smallpox in 1956, and 493 968 were re- vaccina- mainly concerned with institutions which provide ted in the same year.The estimated number of leprosy medical care.This work is being gradually absorbed patients for the whole country is 13 000.The number by the national health administration, in virtue of a of known cases in 1956 was 9298, and 858 patients constitutional provision which authorizes the national were segregated.There are two leprosaria, with a executive to nationalize the hospitals in the interests capacity of 1000 patients.In 1956, 343 cases of polio- REGION OF THE AMERICAS 209 myelitis were recorded, of which 285 occurred in populationinthefive -year period1941 -45,had children under five years of age, and inoculation with dropped to 0.12 per 100 000 in 1956. Salk vaccine was introduced. Altogether 91 086 chil- In 1956, 479 health centres were providing maternal dren were inoculated against diphtheria in 1956 and and child health services, 86 of these being located in 82 335 against whooping- cough. urban and 393in rural areas;136 083 pregnant Tuberculosis control was carried out in 1956 by women in urban areas and 53 612 in rural areas were 87 tuberculosis clinics and one mobile unit.The given pre -natal care.In urban areas, 187 255 ante- total number of x -ray examinations performed in that natal home visits and 33 392 post -natal home visits year was 769 088, and the number of cases thus were made. A total of 196 796 children attended the diagnosed was 6016; 23 136 contacts were also x- rayed. urban centres and 36 701 attended the rural centres; The number of BCG vaccinations effected in 1956 was 957 714 home visits to children were made in the urban 44 755.Several thousand persons were treated with areas. PAS, isoniazid and streptomycin.Important work The Venezuelan Council for Children is responsible is also carried out in syphilis control, the number of for the social, legal and moral protection of homeless serological tests performed in 1956 being 868 012, children, and maintains for this purpose about a of which 150 279 were positive. PAM was admini- hundred institutions for the care, housing and re- stered to 10 216 syphilis cases. education of minors. The results of the Venezuelan antimalaria campaign The social security system introducedin1944 are well known; they are about to lead to the eradica- covered 513 344 persons in 1956, including workers tion of this disease from the country.The original and members of their immediate families.Its benefits malarious area has already been reduced by 60 per are limited to sickness, maternity, occupational acci- cent., and it is hoped that by means of a special plan, dents and occupational diseases.The system does which was put into operation two years ago, the not cover all workers and does not extend throughout disease will be eradicated within the next two or three the country; it is financed by the national Government years.The mortality rate, which was 110 per 100 000 and by contributions from employers and workers.
WINDWARD ISLANDS
The Windward Islands form the eastern barrier to the Carib- The larger towns have up to 20 000 inhabitants, and there bean Sea between Martinique and Trinidad, and consist of are manyscatteredvillages.Communityorganizationis Dominica, Grenada, St Lucia, St Vincent and the Grenadines on the lines of British local government. (of which half are dependencies of Grenada and half are depen- dencies of St Vincent).Each island has its own administrator, executive council and legislative council, and its own institutions; Health there is no common legislature, laws, revenue, or tariff, but the territories unite for certain other common purposes, such as the There is a Central Board of Health, whose chair- Windward Islands and Leeward Islands Supreme Court and man is the senior medical officer.He is responsible Court of Appeal. for five medical districts, each with one or more medical officers. Dominica Dominica has four hospitals, with, in 1947, a total Dominica has an area of 790 square kilometres, and in 1955 bed capacity of 286, distributed as follows: general its population was estimated at 62 242, of whom about 60 per cent. were Negroes. medicine, 193; paediatrics, 20; maternity, 28; tuber- The economy is agricultural, and the chief exports are bananas, culosis, 19; and mental diseases, 26. cocoa, copra and lime juice.There was marked economic The personnel of the government public health progress in Dominica in 1953 and 1954; the export crops in- services include: seven physicians, five public health creased in quantity and value, trade in consumer goods expanded, and building increased. nurses, 47 other graduate nurses, 32 graduate mid- Free primary education is provided, generally with an age wives, 20 sanitarians, one dentist, one veterinarian, range of from 5 to 15, and is compulsory where accommodation one nutritionist, four statisticians, and one laboratory permits.The Government provides a number of scholarships technician.The graduate nurses and midwives are in the secondary schools. locally trained.The nutritionist also works in the Various types of adult education are provided; classes are arranged by women's organizations, and by the Extra -Mural other islands of the Windward group. Department of the University College of the West Indies in The reported birth rates in 1954 and 1955 were Jamaica. 38.2 and 40.9, and the death rates for the same years 210 FIRST REPORT ON THE WORLD HEALTH SITUATION were 12.3 and 14.0.The infant mortality rates for In 1955, the birth rate was 44.4, the death rate thethree -year period1954 -56 were:99.4,120.3, was 13.7, and the infant mortality rate was 76.0. and 132.0. The public health personnel in 1957 consisted of 13 The principal causes of death reported in 1955 physicians, four public health nurses, 73 other graduate were: gastro- enteritis, avitaminosis, diseases of early nurses, 46 graduate midwives, 16 sanitarians, one infancy, tuberculosis, influenza and pneumonia, ty- dentist, one veterinarian, five laboratory personnel, phoid fever, and diseases of the heart.Malaria one social worker, one statistician, and 297 other was stated to be the cause of only two deaths in 1955. workers. The estimated number of cases of yaws in 1956 Medical care is provided in seven hospitals, with was 1734, of which 1698 were treated in clinics. a total of 527 beds, divided as follows : three general There is no medical school in the territory; medical hospitals, with 281 beds; one hospital for infectious qualifications are normally obtained in the United diseases, with 20 beds; one tuberculosis hospital, with Kingdom or in Jamaica.Local training is provided 68 beds; one mental disease hospital, with 148 beds; for pharmacists and sanitary inspectors, as well as and one other hospital, with 10 beds. for nurses and midwives, and initialtrainingis There are also one urban and 25 rural maternal provided for laboratory technicians. and child health centres, serving 72 387 inhabitants. In 1954, roads, water -mains and sewers for a 582 - In1956,3561mothersreceivedpre -natalcare, house project were completed. 3036 children were attended and 7186 visits were made to children at home. Grenada There is no medical school in the territory; medical Grenada has a total land area of 344 square kilometres, and qualifications are normally obtained in the United its estimated population in 1955 was 88 215.More than half Kingdom or in Jamaica.Training is provided in of the population is Negro and the remainder is of mixed origin. theterritoryfornurses,nurse -midwives,health The economy is agricultural, and the principal exports are visitors, pharmacists and sanitary inspectors; initial cocoa and nutmegs. training is provided for laboratory technicians. Free primary education is provided, generally with an age range of from 5 to 17 years, and is compulsory where accom- The water supply is apparently good; the island modation permits. A number of scholarships in the secondary has seven systems in urban areas and 13 in rural schools are provided by the Government. areas. In 1955 there were 12 government primary schools and 41 pri- There is one urban sewage -disposal system serving vate schools, with a total average attendance of 14 338 pupils; one government secondary school and five private, with a total 5800 inhabitants, 4000 of whom are on a connected enrolment of 1307 pupils; and three handicraft centres. system, 400 inhabitants have private septic tanks, A site was acquired in Grenada for a pilot self- housing 1250 have latrines, and 150 have neither tanks nor project in 1954. latrines. Health St Lucia is The senior medical officer chairman of the St Lucia has an area of 616 square kilometres, and an estimated Central Board of Health, and isassisted by the population in 1956 of 89 006 (predominantly Negro), of whom medical officers of each of the medical districts. some 25 000 lived in urban areas. The public health budgets for 1954, 1955 and 1956 The economy is agricultural, and the chief exports are cocoa, were as follows: coco -nut oil, copra and sugar.In 1954 there was a revenue 1954 1955 1956 surplus. BWI $* BWI $ BWI $ Free primary education is provided at 51 schools, generally
Communicable diseases . . 2520 2520 2432 with an age range of from 5 to 15, and is compulsory where Tuberculosis control 13558 11502 11660 accommodation permits.The Government offers a number
Venereal disease control . 17724 19860 19104 of scholarships in the two secondary schools. Malaria control 7820 8100 6100 Various types of adult education are provided by women's Environmental sanitation . 1700 2500 2000 organizations, and by the Extra -Mural Department of the Industrial hygiene 14960 18140 21043 University College of the West Indies in Jamaica. Vital and health statistics . 3756 3756 4808 The Vide Bouteille housing scheme was completed recently Local health services 26936 25996 26968 in St Lucia. Maternal and child health 2710 2765 2765 Dental health 6096 6216 6216 Health Nutrition 5000 5000 4622 Laboratory services 6420 8147 7732 St Lucia has a Medical Department headed by a Hospitals 211176 231069 219917 senior medical officer. Food and drug services. . 200680 214420 180060 There are eight hospitals on the island, with a * BWI $1.70 = US $1.00. total of 477 beds: four general, one for tuberculosis, REGION OF THE AMERICAS 211 one for mental diseases, one for leprosy and one for the island is divided into six medical districts, each the aged.The health personnelis composed of with a district medical officer, district health nurses 10 doctors, 18 public health nurses, 27 other graduate and a public health inspector.District dispensaries nurses, 17 graduate midwives, 10 sanitarians, 46 other are located in suitable places in each district.The sanitation personnel, one nutritionist, one dentist, public health inspectors are responsible chiefly for two veterinarians, three laboratory personnel, one general and environmental sanitation, and the other social worker and 113 clerical and other personnel; district services deal with both curative and pre- practically all are full -time. ventive medicine. The essential vital statistics during the years 1954, In 1954, 13.7 per cent. of the total budget for 1955 and 1956 were: birth rate, 36.1, 40.7 and 40.1; the territory was spent on health. death rate,12.0,11.9 and 12.7; and infant mor- The vital statistics for the years 1954, 1955 and tality rate, 101.3, 98.1 and 101.9. 1956 are as follows: birth rate, 42.0, 47.5 and 46.3; In 1956, malaria, enteritis and tuberculosis were death rate,15.2,14.5 and 12.0; infant mortality among the most important health problems.The rate, 117.4, 118.1 and 106.9. number of reported cases of malaria remained high There are seven hospitals, with a total of 325 beds, although it had decreased from 3642 in 1954 to 1130 including a general hospital with 134 beds, an infec- in 1956.In the same year there were 147 reported tious diseases hospital with 40 beds, a mental hos- deaths from gastritis and enteritis.The provisional pital with 105 beds, a leprosy hospital, and three number of reported cases of tuberculosis in 1956 district casualty hospitals.There are also 13 rural was 67, as against 143 in 1955.Apart from the and seven urban health centres. tuberculosis hospital mentioned above, there is one At the end of 1956 the following personnel were tuberculosis control centre, which provides ambula- employed in the health services: 10 doctors, 21 full - tory treatment only; tuberculosis patients are also time and one part -time district nurses, who also serve dealt with in 14 general health centres. as midwives; 37 other graduate nurses, 32 auxiliaries, Maternal and child health services are provided in 54 graduate midwives, 10 full -time and one part -time 15 centres in both urban and rural areas. A total sanitary inspectors, 60 full -time and 80 part -time of 9777 pre -natal visits was recorded in these centres other sanitation personnel, one dentist, one veteri- in 1956, as well as 6681 visits of children. narian and four laboratory personnel. Medical educationisusuallyobtainedinthe In the year 1955, of a total of 1102 deaths, 337 were United Kingdom and in Jamaica.Nurses, nurse - due to diseases of early infancy, 148 to gastro -intestinal midwives and pharmacists are trained locally.Health diseases, 96 to diseases of the heart, 55 to bronchitis, visitors and sanitary inspectors are trained in Jamaica. 38 to influenza and pneumonia, 35 to whooping - cough, 23 to tuberculosis, and 23 to malignant neo- plasms. St Vincent Yaws, syphilis, and tuberculosis are the main health problems, the number of reported cases for 1956 St Vincent has a land area of 388 square kilometres, and its being: yaws, 410; syphilis, 120; and tuberculosis, 33. estimated population in mid -1955 was 75 958.About 60 per There are 20 known cases of leprosy, all of whom cent. of the population are Negro and the remainder are of are segregated in a settlement. mixed origin. The economy is agricultural, the main exports being arrowroot, Maternal and child health services are provided at copra, cotton and sugar. the general health centres in both urban and rural Primary education is provided free of charge, generally with areas.In 1956 these centres recorded 2787 visits by an age range of from 5 to 15 years, and is compulsory where children to clinic sessions, and 10 032 visits made to accommodation permits. In 1955 there were 41 government primary schools, two children in their homes. government and two private secondary schools, and a teacher - There is no medical school in the territory.Medical training school. qualificationisnormally obtained in the United Since 1947 the Central Housing and Planning Authority has Kingdom or in Jamaica.Training is provided in set up seven villages with about 1000 houses and housing the Windward Islands for nurses, nurse -midwives, schemes containing 250 units.Five new housing areas on which 40 units are to be built privately have also been selected. health visitors, pharmacists, and sanitary inspectors; initial training is also provided for laboratory techni- cians. Health There are 32 systems supplying water to 20 291 The Medical Department is administered from a people, 15 646 of them in rural areas.Public taps central office under the senior medical officer, and or fountains serve 41 829 inhabitants.
SOUTH -EAST ASIA REGION FIG. 8 SOUTH -EAST ASIA REGION AFGHANISTAN Afghanistan is a land -locked mountainous country bordered In 1957, Afghanistan had a total of 190 doctors by the Union of Soviet Socialist Republics, China, Iran and (excluding assistant doctors), 440 male and 160 female Pakistan, with an area of 650 000 square kilometres. 1Most of the land is too dry and rocky for cultivation but there are nurses, 62 midwives and 28 dentists.The Govern- many plains and valleys which are being developed more fully ment employs 150 doctors in the civil service, of whom by irrigation from small rivers and wells.The climate is of about 100 work in Kabul and the rest in the provincial the mountain type. capitals. There has been no general census in Afghanistan but the popu- lation was estimated in 1947 at between 12 and 13 million, of The country is reported to have 37 hospitals with a whom approximately two million were nomadic.The most total of about 1410 beds, 50 per cent. of which are in recent estimate of population in the chief cities is: Kabul, Kabul.There are 20 maternal and child health the capital, 220 000; Kandahar, 80 000; Mazar- i- Sharif, 43 000; centres in the country, of which 16 are in Kabul and Jalalabad, 16 000. one in each of the provinces of Kandahar, Jalalabad, There are four main tribes in Afghanistan, the members of all of which are considered Afghans, without any distinction. Mazar -i- Sharif and Herat.There is a central public There are house dwellers and tent dwellers.People are generally health laboratory in Kabul and one provincial labo- engaged in agricultural and pastoral occupations. ratory in each of the provinces of Kandahar, Jalalabad, Afghanistan is self-sufficient in food production but the eco- Mazar -i- Sharif, Gardez and Mashriqui. nomy is still unstable.In a census of manufacturers made in 1948 there were 23 industrial enterprises -mainly textile factories Communicable diseases reported to be common are : but including some other light industries such as sugar pro- smallpox, typhoid and paratyphoid fevers, dysenteries duction - with a total of 6000 employees.There are govern- (both amoebic and bacillary), typhus, venereal diseases, ment monopolies for the import of motor vehicles and the tuberculosis, malaria, relapsing fever, leprosy, cuta- import and export of sugar and tobacco.Eighty per cent. of neous leishmaniasis and trachoma. the trade goes through Pakistan, the main exports being spices, Typhus has been fruits, karakul skins, carpets and raw wool. decreasing during the past few years, through control There are elementary schools in various parts of the country measures instituted by the Government.Programmes but secondary schools are limited to Kabul and the provincial for the control of venereal diseases have been esta- capitals.Some of the technical, art and commercial schools blishedin Kandahar,Herat,Jalalabad, Mazar -i- provide higher education and the Kabul University, founded in 1932, has faculties of law, science, medicine, theology and Sharif, Gardez and Kataghan.Malaria control work, arts. which has been in operation since 1948, was expanded There are no railways in Afghanistan and water transport in 1952 to cover the entire country and has proved so is used for timber only.The number of roads fit for motor successful that an eradication campaign has recently traffic is increasing; all the provincial capitals are now connected been started. by motor roads with Kabul, and much of the merchandise is For tuberculosis control, there are the carried by lorries.Six of the more important provincial cities Chaman tuberculosis control demonstration and train- have regular airline connexions with Kabul.The main pro- ing centre in Kabul and the female and male tubercu- grammes of development are in irrigation and transport. losis sanatorium units at the Aliabad hospital. Since 1956 domiciliary treatment by chemotherapy was Health introduced in the Chaman centre, covering about 50 000 people in Kabul. The Minister of Public Health and his deputy head Following the demonstration of an integrated ap- a ministry comprising three directorates -public health proach for rural development in a few villages in the services, general administration, and the Public Health Shewaki area, about 16 km from Kabul, the Govern- Institute.The first is responsible for all the technical ment has recently, under Royal Charter, adopted a services and the second for finance, personnel and first five -year plan for rural development.The project general services.The Public Health Institute isin in the Shewaki area started in 1954 as a rural health course of establishment and the director is at present unit serving eleven villages.The unit now consists in charge of training, which will be one of the functions of a health centre, one sub -centre and five visiting of the Institute. points with a staff of a doctor, an assistant doctor, Healthadministrationineachof the thirteen two midwives,onesanitarian,two compounders provinces is under a Director of Health, who is re- and one vaccinator serving approximately 30 000 sponsible for both curative and preventive work and people in the area.Since1956, the Government is also in charge of the central provincial hospital. has developed this demonstration and training area with technical assistance from the United Nations 1 Unofficial estimate published in: United Nations, Statistical and five of the specialized agencies.Students from Office (1957) Statistical Yearbook, 1957, New York, p. 25 the Sanitarians' Training School, the Female Nurses' - 215 - 216 FIRST REPORT ON THE WORLD HEALTH SITUATION
Training School and the School of Midwifery in In 1957 there were 212 medical students in the faculty. Kabul undergo a period of practical training in the Nurseshaveathree -yeartrainingcourse -male area. nurses at a school associated with the Aliabad Hos- Medical students are trained in the medical faculty pital, and female nurses at a nursing school at the of the University of Kabul, where the curriculum Masturat Women's Hospital.Midwives followa combines preventive and curative medicine.Thirty - 20 -month course in the midwifery school at Shahrara three medical students graduated in 1956, and all maternity hospital.In 1956 a three -year course for of them have been employed by the Government. sanitarians was introduced.
BURMA
The Republic of the Union of Burma forms the western second language from the fifth grade onwards.Education in portion of the sub -continent of Indo- China; its neighbouring all its branches is free.The rate of literacy has been reported countries are Pakistan, India, China, Laos and Thailand.It lies as about 60 per cent. throughout the Union. A State school between latitudes 10° and 28° north and longitudes 93° and of fine arts, music and drama was inaugurated in Rangoon in 103° east, and falls into three well -marked natural divisions: the 1952. A mass education council, through educational centres western hills, the central basin, and the Shan plateau in the set up in various rural areas, endeavours to eradicate illiteracy east, with a southward continuation of this highland in the in the country and to spread elementary education and basic Tenasserim.Apart from the mountain ranges, there are a knowledge in economics, citizenship, culture and health amongst series of river valleys and two coastal strips on the Bay of the adult rural population. Women participate fully in social Bengal.The area of the Union is 677 950 square kilometres. life and take an important share in agriculture. r The climate is of a characteristically monsoon type, with three seasons -the rainy, the hot and the cold.The temperature Health in the hot season in the Delta is about 38° C, while in the dry zone it may be slightly higher.During the cold season the tem- The Burmese Health Administration is centralized perature may drop to about 15° C in South Burma, and may fall even lower in the dry zone in the north.The Delta and the in the Ministry of Health, under the Minister of coastlands are humid all the year round.There are wide Health.The Director of Health Services, who is variations in rainfall. responsible to the Minister for carrying out policy and According to the official estimate, the population of Burma at managing the health services,isassisted by four mid -1956 was 19 855 560.The population is composed of Deputy Directors in charge respectively of hospitals many ethnic groups, each with its own language and customs. Burmese of mongoloid stock form the main group, other large and dispensaries, public health, maternal and child groups being Indian, Pakistani, Chinese, European and Anglo- health, and laboratories. A National Health Council Burmese. advisestheGovernment onhealthmatters. A The rural inhabitants comprise 85 per cent. of the population. number of voluntary organizations are also engaged In the villages, homes are constructed of bamboo poles, with in health activities. bamboo mats for walls, split bamboo tied together for the floors and a straw roof; these dwellings are always built well above At the district headquarters level, the work is in the ground on stilts. the charge of the District Health Officer, who, except For purposes of administration the Union is divided into in four districts, is also the Civil Surgeon and thus in Burma proper, with the special Chin division and four constituent charge of both curative and preventive work.In autonomous States of Shan, Kachin, Karen and Kayah.Burma proper is divided into eight divisions, including the Chin division. districts with a full-time district health officer, the Each division is split up into districts, each district into sub- work is divided between him and the civil surgeon. divisions, each subdivision into townships and each township At the local level, there are township medical officers into village tracts composed of a number of hamlets.Each and other health staff, and the public health work is division is under the administration of a Commissioner, each based on urban and rural health centres. district is under a Deputy Commissioner, each subdivision is under a subdivisional officer, each township is under a township Since the war, complete registration of vital statistics officer and each village tract is under a headman. has only been effective in certain of the large towns The main means of livelihood is paddy cultivation, on which and in a few rural areas which are designated as the economy of the country is largely dependent.Three- quarters registration areas.The population of the 78 large of the cultivated land is devoted to rice- growing, other crops being vegetables, fruit,maize, cotton, groundnuts, tobacco towns thus covered amounts to just over two million. and, to a lesser extent, wheat and sugar -cane.Burma is noted On the basis of the experience gained in the registration for its teak and rubies.It produces oil and has rich deposits of areas, the Government is planning to make a gradual lead, silver, tin, zinc, iron and wolfram.Rice accounts for improvement in the system of reporting and recording about three- quarters of the exports. statistics theentire In almost all villages of Burma, Buddhist monasteries have vital and health throughout provided rudimentary education from very early times.Burmese country.According to statistics from the registration is the medium of instruction, with English as a compulsory areas, in 1955 the birth rate was 35.9, the death rate SOUTH -EAST ASIA REGION 217 was 21.8, the infant mortality rate was 167, and the ing the economic development of the country. A sys- maternal mortality rate was 5.8. tematic nation -wide malaria control programme was There are 241 government general hospitals in the initiated in 1952; by 1956 a total of 58 malaria control Union (45 district, 140 township and 56 other smaller units were in operation, and 6.3 million people were hospitals) with a total of 11 310 beds, and nine non- directly protected by the campaign. governmental general hospitals with a total of 940 beds. Leprosy is prevalent throughout Burma and is also There are also seven specialized hospitals for maternity, an important health problem.The number of cases psychiatry, leprosy, tuberculosis, paediatrics and con- in the Union is estimated at about 200 000.There are tagious diseases, with a total of about 2000 beds. special clinics for diagnosis and treatment of am- Among other health establishments provided by the bulatory patients, and in- patient accommodation is Government in 1956 were 133 dispensaries, 12 urban provided in leprosaria and settlements for selected health centres and 296 rural health centres.The cases suffering from the lepromatous form of the rural health centres are distributed throughout the disease, which is the type most commonly found in country, and it is estimated that their services cover Burma.Thereare21suchestablishmentswith some 4 440 000 people in rural areas. accommodation for 3675 patients.Altogether 30 995 The Union has, in government service, a total of leprosy patients were treated in1955, asagainst 393 physicians, 553 trained nurses, 241 women health 3537 in 1951. visitors, 654 midwives, 371 compounders, 44 labora- The problem of tuberculosis seems to be of con- tory assistants, 264 health assistants, 26 trained public siderable magnitude in Burma.Statistics obtained health nurses and 230 vaccinators. from tuberculin- testing (as part of the BCG campaign) The shortage of medical and para- medical staff show on the whole a high rate of infection: 28 per cent. of all categories is a serious problem. Undergraduate up to 6 years, 53 per cent. up to 14 years, and 81 per medical education is provided in two medical schools, cent. for 15 years and over. A control programme in Rangoon and Mandalay, and there were 94 gra- was initiated in 1951; in addition to a mass BCG vac- duates from both in 1956.Post- graduate training in cination campaign, tuberculosis clinics with mass x -ray public health has to be obtained abroad.In 1956 equipment were established in Rangoon and Mandalay, a 12 -week public health course was offered to 11 and a 200 -bed tuberculosis ward was added to the medical officers.The training of nurses is under- Rangoon General Hospital.By 1956, ten teams were taken at schools attached to six government hospitals, engaged in the BCG programme, and sincethe at one State training school and at two non- govern- beginning of the campaign 4 416 435 persons had been mental schools.In 1956 there were 477 student tuberculin- tested and1 378 505 had received BCG nurses and 85 graduate nurses studying in these vaccination. institutions.Training facilities for other types of A venereal disease control programme was started health worker include courses for health visitors in in 1951, and by 1956, 15 anti -venereal disease district Rangoon (47 graduates in 1956); for midwives in teams were operating in the Union.Total attendance Rangoon, Mandalay and in 33district hospitals at clinics in 1956 was 180 038, compared with 214 482 (a total of 314 graduates in 1956); for health assistants in 1955; and 66 687 new cases were discovered in 1956, at the Health Assistants' School, Rangoon (a total of as against 87 062 in 1955.Blood samples taken for 429 by 1955 since its establishment in 1950); and for serological tests for syphilis during these two years laboratory technicians at the Pasteur Institutein also showed some decrease in the percentage of Rangoon (eight graduates in 1956). positives -16.3 per cent. in 1955 and 15.2 per cent. From the statistics available, it appears that the in 1956. incidenceof cholera was decreasing duringthe Before maternal and child health services were taken three years under review, with only six deaths in 1956; over by the Directorate of Health Services in 1953, plague and smallpox were still prevalent, but to a this work had been carried out, mainly in Rangoon considerably lesser extent than in the years before 1952. and a few large cities, through the efforts of a great The incidence of beri -beri appeared to be high, many private and voluntary agencies.The Directorate with a total of approximately 5000 cases reported by of Health Services now contains a Division of Maternal 288 hospitals and dispensaries throughout the country and Child Health under the charge of a Deputy in1955.In 1956, 498 deaths from typhoid and Director and two assistant Directors, one for MCH paratypoid were registered in 63 towns -a rate of and the other for school health.Efforts are being 24 deaths per 100 000 population. made by the Directorate of Health Services to in- Malaria affects over half the population and is con- tegrate MCH services into the work of urban and sidered to be the most important health hazard retard- rural health centres; in rural areas thisisbeing 218 FIRST REPORT ON THE WORLD HEALTH SITUATION accomplished, but in the large cities -particularly in were also in progress at the end of the period under Rangoon, Mandalay, Bassein and Moulmein- pro- review. gress has been slow.By the end of 1956, 12 of these Environmental sanitationisdealt with by the integrated health centres had been set up in Rangoon, Ministries of Health, Social Welfare, and Housing Mandalay, Moulmein and Bassein.Each of the and Works.Only a few of the major towns have 296 rural health centres provide ante -natalcare, adequate piped water supplies, which are derived although not all of them have yet been provided with mainly from upland streams or deep. wells. A recent an adequate number of midwives and female health survey of 65 major towns showed that over 60 per visitors. cent. of them had no water -supply system, and less Dietary and nutrition surveys have recently been than 10 per cent. had an adequate water supply. carried out among schoolchildren and invillages, For rural areas, a Rural Sanitation and Water Supply revealing that the diet of the villagers is lacking in Board under the Ministry of Social Welfare has the vitamin A, calcium, thiamine and riboflavin, and that specific function of providing the rural population itis also deficient in animal protein.Among the with clean drinking -water and distributing cement slabs schoolchildren examined, deficiency in all essential for the construction of fly -proof latrines.By the end vitamins was evident, and anaemia and caries were of 1956, 2190 tube wells had been sunk in 18 rural found in a high proportion of cases.Surveys of districts, and 7974 latrines had been constructed with nutritional diseases, including goitre and beri -beri, the help of mass education workers.
CEYLON
Ceylon lies in the Indian Ocean just south of the tip of the air services have been developing rapidly, and a national airline Indian sub -continent.The length of the island from north to operates regionalservices between Colombo and Madras. south is 435 kilometres and its breadth from east to west 225 kilo- There is also an internal service, and many international airlines metres.The area is 65 610 square kilometres.There is a call at Colombo.Railway services extend to 1400 kilometres, mountainous region in the south centre, which rises to as much but road development is becoming relatively more important; as 2550 metres above sea level and is surrounded by an upland there are now about 100 000 motor vehicles in service. belt ranging from 300 to 900 metres.Below this is a narrow coastal plain which broadens into a wide belt in the north. Health Forest, jungle and scrub cover most of the island. The climate is warm throughout the year, with a relatively In the Central Department of the Ministry of Health high humidity.The rainfall generally is heavy, with marked the Director of Health Services has three Deputy regional variations.About 14 200 square kilometres are under Directors, one in charge of curative services, one cultivation, and there are a further 18 425 square kilometres of dealing with preventive work and the third in charge pasture -land. of laboratoryservices.Thereisalsoastaff of At the 1953 census the population was just over eight million, nearly 70 per cent. being Sinhalese; Ceylon and Indian Tamils administrative officers.At the beginning of 1954 the accounted for 23 per cent. and Europeans numbered only 6508. decentralization of the Department was begun with In 1956 the population was estimated at 8 929 000.The main the creation of 15 administrative health districts, each occupation of the people is agriculture, with some mining, and under a superintendent of health services.Each of there is growing industrial development. For general administration, the island is divided into nine these divisions has been further subdivided into four provinces, with 21 districts, each presided over by a Government or more health areas, known as health units, each Agent, with assistants and subordinate headmen.There are covering a population of about 50 000.The full seven municipalities, 36 urban councils and 38 town councils. staff required for such a unit consists of one medical The island is an important exporting country, the chief items officer of health, five public health nurses, five public being tea, rubber, coco -nuts, copra, coco -nut oil, coir, and cocoa. The chief mineral export from Ceylon is graphite. health inspectors and 10 public health midwives.At Primary education for the age -group 5 -11 is universal and is present there are 97 health areas; of these 44 are in given in the mother tongue.English is taught as a second the charge of medical officers of health, and three are language from Standard 2. supervised by district medical officers doing health Social security schemes are developing and ordinances relating to the relief of the poor came into force in 1940.Their provi- work and are run on health unit lines.Of the sions were applied at first to the towns of Colombo, Kandy and remaining 50 health areas, 47 are in the charge of Galle, where the local authority is responsible for administering supervising public health inspectors, and three are in and financing poor relief.In other areas the administration is the charge of district medical officers doing part -time undertaken by the central Government, with the assistance of health work.The duties of both types are similar, advisory committees. Ceylon is an important centre of communications and many except that the latter are not concerned with maternal ocean -going vessels enter the port of Colombo.In recent years and child health or school health services. SOUTH -EAST ASIA REGION 219
The percentage of the general government budget Registration of births and deaths is compulsory in devoted to health and medical services was 11.55 Ceylon.The birth rate was 37.0 in 1956, and the in 1954/55 and 11.08 in 1955/56. death rate was10.1.Infant mortalityisfalling In 1955 the personnel employed in the Medical steadily, and reached the rate of 67 in 1956. Services Division of the Department of Health in- The changes in the vital statistics of Ceylon have cluded 836 medicalofficers,48dentalsurgeons, been dramatic during the past half -century.The 990 apothecaries, 1786 matrons, sisters and nurses, crude death rate for the island at the beginning of the 424 pupil nurses, and 623 midwives.The Public century was well over 25, the rates for the decades Health Services Division included 105 medical officers 1901 -10,1911 -20,1921 -30 being 28.7,30.8,and of health, two medical officers doing health work, 26.2 respectively.The rate improved steadily up to 15 divisional supervising public health inspectors, the malaria epidemic of 1934 -35, when it shot up 53 supervising public health inspectors, 774 public to 36.5From that point there was a steady decline healthinspectors,108publichealthnurses,17 to19.8 in 1946.The antimalaria DDT spraying ankylostomiasisdispensers,41male vaccinators, campaign of that year resulted in a drastic reduction eight female vaccinators and 1186publichealth of the death rate to 14.0 in 1947, since when it has midwives. declined gradually to its present figure.The infant There is a Faculty of Medicine in the University mortality trend has been roughly parallel with the of Ceylon, and doctors in public health receive their general mortality.The rate in the island in 1931 training in short -term courses arranged by the Govern- was 158, and rose to the peak of 263 following the ment, and by study abroad.Dental surgeons are malaria epidemic.In the following decade the rate alsotrained inthe Faculty of Medicine.There improved appreciably and dropped to 101 in 1947; are training schools for nurses at Colombo, Kandy as shown above, it is still on the decline.Some of the and Galle, and midwives are trained in four hospitals, principal causes of death are pneumonia, cancer, with domiciliary training at certain health units. tuberculosis and typhoid.Among children gastro- Public health inspectors receive a six months' training enteritis takes a heavy toll.The disease known as course at the Kalutara Health Unit. mandama occurs mostly inrural areas and isa All rubber, tea and cocoa estates of over 10 acres common cause of death; it is presumably connected are scheduled under the Medical Wants Ordinance for with malnutrition. the care of the sick.In 1955 there were approximately Up to late 1954, all maternal and child health work 2335 estates so scheduled, with an approximate labour in rural areas was under the Sanitary Services Section population of 1 014 897.In 1955 the Government of the Department of Health Services and was carried employed two full -time inspecting medical officers out wholly throughthehealthunits.With the and 45 part -time medical officers.It also maintained reorganization of activities in areas other than those 66 hospitals and 116 dispensaries in the estate medical in the charge of medical officers of health, the work is districts, in the charge of qualified medical officers and carried out by the peripheral units and by doctors from apothecaries who rendered medical aid to the estate nearby hospitals.The following figures indicate the and indigenous population.In addition, the estate extent of the work done : authorities maintained 94 estate hospitals and 684 es- 1954 1955 tate dispensaries for the exclusive use of plantation Number of health centres holding MCH clinics 744 768 workers, employing three medical officers, two Indian - Number of clinic sessions held 24 556 30 851 qualified licentiates,12 qualified apothecaries and Number of public health nurses 97 108 536 dispensers. Number of homes visited 58 098 81 638 The following table shows the number and bed Number of midwives * 1 336 1 186 Number of homes visited 296.962 306 577 capacity of medical establishments at the end of Number of mothers delivered by midwives 72 594 80 149 1955: Number Beds ° The 1954 figure includes midwives attached to maternity homes; in 1955 these are excluded. Colombo group of hospitals 7 2 624 Provincial, base and district hospitals . 121 12 962 Peripheral units 52 1 412 School health services cover only the English, Rural hospitals 68 1 451 Sinhalese and Tamil schools, which number 5888 Maternity homes 107 1 170 and have an enrolment of1 572 645 pupils.The Specialinstitutes(tuberculosis,leprosy, number of schoolchildren examined in1955 was mental, infections diseases and prison 130 636. hospitals) 26 5 863 Dispensaries (central) 283 - The control of the environment is the special con- Private nursing homes 46 - cern of the Division of Public Health Services. A 220 FIRST REPORT ON THE WORLD HEALTH SITUATION pilot project was started in 1955 with the aim of introduced an aided scheme of construction, and under working out simple sanitary improvements in rural this and other plans nearly 40 000 latrines were water supply and excreta disposal, testing them on a installed in 1954 and more than 37 000 in1955. pilot scale, developing rural programmes in environ- Ceylon has a scheme of rural sanitation which is mental sanitation and training national sanitation playing an important part in the improvement of workers; for this purpose the construction of sanitary sanitary and health conditions in rural areas.Among facilities is being demonstrated in two areas, one a dry the practices that householders are encouraged to zone and the other a wet zone. A great deal has yet adopt are the use of boiled water for drinking purposes, to be done towards the general provision of a protected the provision and use of a sanitary latrine, the disposal water supply.Recent investigations have shown that of refuse in compost pits, and the cultivation of a only one in three houses in Ceylon is provided with vegetable garden where the compost can be used as sanitary latrine accommodation; the Department has a fertilizer.
INDIA
The Republic of India is a federation of states, comprising The school system may be divided into four stages: nursery, 14 major states and some union territories.Its area is 3 288 375 primary, middle and high.The last two combined constitute square kilometres.The estimated population of both states the secondary stage.As yet there are only very few nursery and territories in mid -1955 was 382 390 000, compared with schools.Primary education covers a period varying from four 377 130 000 in 1954.The average population density for 1955 to six years, and a number of states have now made provision was about 116 per square kilometre.On the Ganges plain for compulsory attendance.The period for the middle stage the density is much higher.The capital, New Delhi, had in 1951 varies from two to four years and the high school stage has the a population of 276 314.According to the 1951 census, 83 per same limits.Higher education is given in arts, science or cent. of the population were rural.In 1955 there were 85 cities professional colleges, in the universities and in the All -India with a population of more than 100 000 inhabitants and 228 educational or research institutions.Teaching is generally in towns with from 30 000 to 100 000 people. English.In 1950 there were 29 universities, of which the most A Council of Ministers aids and advises the President of the important are probably those of Calcutta, Bombay, Madras Republic in the exercise of his functions.Among the Ministries and Allahabad. in the Cabinet are Education; Health; Food and Agriculture; At the end of March 1955, railways covered a total of 55 850 Works, Housing and Supply; and Labour. kilometres.There were some 390 000 kilometres of all- weather On the local government side in 1948 there were nearly roads: the national highways, which connect the capitals of 50 000 municipal authorities serving a population approaching states, the chief ports and foreign highways; the state highways, 17 million.These bodies are entrusted with the lighting and which are the main trunk roads of the states; and the district maintenance of roads, water supply, drainage, sanitation, as roads, which connect areas of production with distribution well as the personal services of medical relief, vaccination and centres.The road system is still insufficient for the country's education.They impose taxes and enact by -laws with the sanc- needs and its development is one of the main items of the five - tion of the state government.In all the larger and in some year plan.Civil aviation is well developed.All the airlines of the smaller towns the majority of the members of the councils were nationalized in 1953.They now operate over 50 000 kilo- are elected by rate -payers.In many municipalities women metres of scheduled services. are entitled to vote and in some of them they are also eligible A State insurance scheme was introduced in Delhi and Kanpur for election.In the rural areas there are district and sub- with effect from February 1952 and in Punjab from March 1953. district boards or councils, which are in charge of roads, district Schemes of this kind are being extended to other centres.The schools, markets, public health institutions, etc. present information is that at the end of the fiscal year 1953/54 The economy of the country is based principally on agriculture. about 152 000 persons were covered for maternity and sickness At least 250 million of the inhabitants are dependent on this benefits and employment injury, and 268 272 for medical care. occupation.Most of the agricultural holdings are very small - less than two hectares.Food crops occupy four -fifths of the cultivated land.There are at least 150 million cattle -about one -quarter of the world's cattle population.The chief imports Health are machinery and vehicles, implements, metals and manu- factured goods, electrical goods and raw cotton.The principal Matters connected with health fall largely within the exports are cotton piece -goods, jute and tea. sphere of responsibility of the state governments, The first five -year development plan of the Indian Republic under a Department of Health in each state. The was launched in1951 -52.Itslong -term purpose was to double the income per head by the end of 27 years.The Central Government is concerned mainly with inter- immediate purpose was to increase the national income by national health matters, assistance towards and co- 11 per cent. in the first five years.The second five -year plan, ordination of stateactivitieswith theobject of encouraged by the success of the first, proposed to increase achieving uniformity of action and approach, estab- the national income by 5 per cent. during each year of the five -year period.Production is mainly in the hands of private lishing standards, and promoting research and educa- enterprise. tion, particularly in the post -graduate sector. SOUTH -EAST ASIA REGION 221
A Central Council of Health was established in 1952, pneumonia and bronchitis.Very little information is with the Union Health Minister as chairman and the available about the last two but a large number of state Health Ministers as members, to consider and deaths are ascribed to tuberculosis. recommend broad lines of policy with regard to In its first five -year plan the Government of India health in all its aspects, including remedial and pre- concentrated on BCG vaccination for the people as ventive care, environmental hygiene, nutrition and a preventive measure, and the campaign continued to health education and the promotion of facilities for receive the highest priority during 1955 -56.During training and research. 1955 over 22 million persons were tested, of whom The progress of health schemes included in the over 8 million were vaccinated.From the beginning first five -year plan was reviewed in July 1954, and of the campaign in 1948 up to the end of 1955, certain readjustments and reallocations were made, 66.5 million persons were tested for tuberculosis and suchas increased provision for tuberculosis and approximately 22.6 million of them received BCG leprosy control, and water -supply schemes; some new vaccination.At present there are 128 campaign units schemes were also added, such as the establishment of each consisting of a doctor and six technicians. departments of social and preventive medicine in Tuberculosis centres were established in New Delhi, medical colleges, and rural health centres. Trivandrum and Patna in 1950, 1951 and 1952 res- Other health schemes and achievements during 1955 pectively, and eleven more centres of this kind are included the establishment of a child guidance clinic proposed in the second five -year plan.The number at the College of Nursing in New Delhi, increased of tuberculosisclinicsinthecountry has now training facilities for 35 nurses at the Lady Hardinge reached 185. Medical College and Hospital in New Delhi, and the There are now three cancer institutes in India, the publication in November of the Indian Pharmacopoeia. chief of which is the Indian Cancer Research Centre of General progress has been made in malaria control; Bombay.The second is the Chittaranjan National BCG campaigns against tuberculosis; maternal and Cancer Research Centre in Calcutta, and the third was child welfare and the training of nurses, midwives, opened in Madras in 1955 with grants -in -aid from the dais and health visitors. A contributory health scheme Government of Madras and the Government of India. introduced for Government employees in 1954 con- Special methods of early diagnosis have been estab- tinued to expand in 1955.Furthermore, the All - lished and a large amount of general research work India Mental Health Institute has been established in is being carried out. Bangalore and research is being extended into various The National Malaria Control Programme, which fields which have a bearing on health programmes. A started in 1953 -54, has succeeded in considerably family planning scheme has been introduced. reducing the prevalence of malaria in the country. The birth rate was 27.0 in 1955 compared with The number of malaria control units in 1955 -56 reached 24.4 in 1954; the general mortality rate was 11.7 132.During the year 30 medical officers, 139 malaria in 1955 as against 12.5 the previous year, and the inspectors and 10 entomologists were given training infant mortality rate was approximately 100 in 1955 in malariology at the Malaria Institute of India. compared with 115 in 1954. Services for the health and welfare of mothers and Smallpox is responsible for nearly one per cent. young children form an integral part of the pro- of the total mortality and has a large case incidence in grammes of community development. In 1954 training nearly all the states.Cholera attained its peak in most programmes were expanded and the staffing of ma- of the states in the months of January, April -June and ternal and child health centres was brought into line August in 1955, with a case -fatality ratio of 20 -50 per with that of the primary health centres.Central cent.Mass inoculation and other measures such as assistance to states to develop maternal and child disinfection of water supply were carried out where health centres included aid to community projects the disease was most prevalent. and national extension services for training pro- Some deaths occurred from plague during the grammes for different types of workers and also for year 1954, but there has been a steady improvement in undertaking maternal and child health services in the situation in general, as a result of the measures certain backward areas. adopted: flea and rodent control and the use of DDT, Considerable expansion of thestaff of health and other pesticides, as well as plague inoculation. visitors is needed for the maternal and child health Diarrhoea and dysentery accounted for a large services, and financial assistance is being offered for number of deaths in certainstates, but a gradual training.There is an acute shortage of midwives, decline can be noticed in the mortality from these and to meet the demand a training course for auxiliary diseases.Respiratory diseases include tuberculosis, nurses and midwives was started in 1954 with assis- 222 FIRST REPORT ON THE WORLD HEALTH SITUATION tance from the community development programmes. Non -governmental organizations have continued Eighty -five midwives and 231 auxiliary midwives were their work of giving relief to undernourished children trained during that year. and nursing mothers and have rendered assistance in The various states of India have carried out nutrition flood -stricken areas. The Indian Red Cross Societies surveys and these have been followed up by feeding and the Indian Medical Associations have provided programmes, especially for expectant mothers and social help. A very large number of people attended young children, which are now carried out by all courses of instruction on first aid, home nursing, states.The diets in general were found to be un- hygiene and sanitation, mothercraft and child welfare, satisfactory; those in rural areas sometimes contained all under voluntary auspices. a higher percentage of cereals and pulses than those Certain departments of selected medical colleges of the urban populations, and there was a lack of and research institutes have been upgraded since 1948 vitamins, animal protein, vegetables, oils and fat, sugar in seven of India's institutes.Departments of social and fruits.Education and publicity measures have and preventive medicine were established in medical been carried out by exhibitions, cooking demonstra- colleges in Darbhanga and Madras.The All -India tions, and other activities. Institute of Medical Sciences in New Delhi is gradually Lack of facilities for mental hospital treatment has being expanded. led to overcrowding.Psychiatric clinics, which have Low -cost housing schemes were started in 1954, been attached to various hospitals in Calcutta, act and the Community ProjectAdministrationhas largely in a custodial capacity, with occupational reconditioned 102 520 houses and constructed 15 517 therapy as the main line of treatment. new dwellings for the staff.
INDONESIA
The Republic of Indonesia consists of a group of islands It is difficult to define the rural population with any accuracy; situated between 95° and 141° east, and 6° north and 11° south. the municipality of Djakarta, for example, contains large popu- It comprises three large islands -Java, Sumatra, and Sulawesi lous areas which are yet rural in type.In any case the rural (Celebes) -part of Kalimantan (Borneo), and some 3000 smaller population forms a very high proportion of the whole -pro- islands.The area of the Republic of Indonesia is1 904 346 bably about 80 per cent. A good deal of internal migration square kilometres. takes place between rural and urban and semi -urban areas, and The islands are mostly mountainous and volcanic, with low - the Government is encouraging people to move from densely lying plains in the coastal regions.The highest mountains are populated Java to underpopulated areas in the other islands. Kerintji in Sumatra (3800 metres) and Semeru in Java (3700 For administrative purposes the countryisdivided into metres).In the various islands there are a large number of provinces (which under the Constitution have broad regional short and turbulent rivers, few of which are navigable. autonomy), one special area (Jokjakarta) with the status of an The climate is tropical except in the higher altitudes, with a autonomous territory, and into regencies, sub -districts and dry season from May to December and a rainy season from villages.Immediately after attaining independence, the Re- November to April.In general, the temperature is about 25° C, public of Indonesia was a federation of states; it was made a with no greater seasonal variation. unitary State in 1950.Among the Ministries in the Cabinet The rainfall is abundant in Java, where the annual average are Public Works, Education, Health, Social Affairs, Labour, at Djakarta is about 183 centimetres.In Sumatra and Borneo and Agriculture. the rainfall varies a great deal but in general is greater than In the western part of the country the main food crop is rice. in Java. In the Moluccas, the emphasis is on sago.Other additional No population census has been held since 1930.The most crops are cassava, maize, sweet potatoes, peanuts and soya recent official estimate gives the population of Indonesia at the beans.The important commercial crops are rubber, copra, beginning of 1956 as 82 583 000.It is estimated that 66 per palm oil, coffee, tea, cocoa, cane sugar and tobacco.Fishing cent. of the people live in Java, which has a population density and livestock rearing are also common occupations.Nearly of 393 persons per square kilometre, and 34 per cent. inhabit 70 per cent. of the population are engaged in agriculture and the outer islands, where the density is 20 persons per square related production.Indonesia is rich in minerals: petroleum, kilometre.For the whole area of Indonesia the average den- tin, coal and bauxite are the principal products.There are sity of population is 53 persons per square kilometre. also considerable deposits of gold, silver, manganese, phosphates, The people of Indonesia belong for the most part to the nickel and sulphur.Among exports are rubber, tea, copra and sub -group of Malayans of the Mongoloid group, except for the palm oil.The production of petroleum is declining and its populations of the islands east of Sulawesi (Celebes) and Lom- domestic use is on the increase.Main imports are machinery bok, who belong to the Melanesian Negroids (Papuan group). and electrical equipment, vehicles, chemicals and drugs.Pro- The estimated distribution of population by ethnic group in duction is normally under private ownership but new plans de- 1952 was: Indonesians, 75 million; Europeans, 240 000; Indo- veloped under the Economic Urgency Scheme are sometimes run nesians of Chinese origin,1 200 000; Indonesians of Arab by the Government -at least in the first stages.The production origin, 70 000; nationals of other Asian origin, 45 000. of staple foods appears to be adequate for the local demand. SOUTH -EAST ASIA REGION 223
Indonesia has prepared its first five -year economic develop- direction. Thedesa,orvillage,whichfrom ment plan, which is to run from 1956 to 1960.It has been early times has formed a well- recognized political, realized that increasing economic productivity is the only means of increasing net income faster than the increase of population. social, and economic unit, has been made the smallest The Government proposes to achieve this by developing existing unitforhealthadministration.The desa has a natural resources and by improving the number of skills of the populationofabout3000 -5000.Theseprimary labour force.In the five -year plan the Government envisages units are grouped in sub- districts of about 23 000- three sectors: the public sector, the private sector, and the village community sector. 30 000 people.The regency headquarters will have In 1954 there were in all Indonesia 49 430 kilometres of general and special hospitals, providing a total of roads.Most of the villages in Kalimantan, Sulawesi and 400 -600 beds, and allconsultant and laboratory the Moluccas have to be reached by boat.In 1954 there were services.Branch hospitals will be established in the 4840 kilometres of railways in Java and 1446 kilometres in surrounding districts with a capacity of 20 -60 beds, Sumatra.The railway systems in north, central and south Sumatra are not interconnected.Excellent plane services link and out -patient clinicswill be distributed in the all provincial capitals and major towns. villages. A tremendous effort is being made to improve education. The medical and para- medical staff of the regency Hundreds of new schools have been opened and are working healthdepartmentwillexercisesupervisionand sometimes on three shifts to meet the great demand.Adult education is also being attempted in order to catch up with control over the village and sub -district health units modern needs.The school situation is as follows: there are and perform certain functions of health care at regency 587 pre -schools, 31 802 primary, 1640 secondary, 635 technical level, such as hospital treatment, tuberculosis clinic and 828 teacher -training schools.Higher education is offered work, etc.The distribution of personnel and their at the University of Indonesia in Djakarta, which has nine functions are as follows: faculties.It had nearly 7000 students in 1953.The State University, Gadjah Mada, has six faculties and some 6000 stu- (1)Village health unit: a village hygienist in charge dents.New universitiesare those of Surabaya, Bandung, of publichealth education,supervisionof rural Medan, Makassar and Bukittinggi.The National Academy, with four faculties, has about 500 students and there is a sanitation,collecting of vitalstatistics;a female Technical Faculty in Bandung with 2000 students.In addition home -visitor for the MCH service; an assistant mid- there is an Islamic University at Bukittinggi, a Christian Uni- wife; an assistant nurse for the treatment of minor versity at Djakarta, and, finally, a school of navigation at ailments. Surabaya. (2)Sub -district health unit: an elementary hygiene Health (health)educator;a nurse -midwife with a short Public health in Indonesia isthe responsibility training in public health; a clinical nurse; a school of the Ministry of Health, which is the supervising health nurse; all types of medical personnel working and co- ordinating body that determines the policy in co- operation with other departments. of the medical and the health service. The autonomous (3)Regency health department: a physician; a provincial governments are the executive authorities sanitary inspector (assisted by special types of health for carrying out programmes and financing them from workers, such as malaria assistants); a public health their own resources, sometimes with a grant from nurse;a nutritionist;adentist;a dental nurse; the Central Government.Under theMinister of additionalstaff appointedforcampaigns against Health there is a Secretary- General for Health.The diseases prevailing in the area concerned. central department has 13 divisions: administration; hospitals; dental health; school health; control of Health centre areas of similar structure are operating communicable diseases, epidemiology and quarantine; in the city and in the regency of Bandung, in Magelang, plague control; leprosy control; sanitation and hous- in Banjumas, and in an area of the city of Djakarta. ing;pharmaceutical matters;maternal and child Recently a health centre area has been laid out in health;international health work; and education. Bekasi. In 1956 a division of rural health and health education The proportion of the general budget allotted to was added.Through a co- ordinator, the regency the Ministry of Health for the years 1952 -55 was director supervises the sub -district health services and 1.9, 1.2, 2.0, and 1.9 per cent. the work in the villages. Accurate statistics are not in most cases available In the health organization there are two types of in Indonesia.The Central Statistics Office estimated local area,the regency (predominantly rural) and at the beginning of 1956, however, that the birth rate the municipality (urban). Rural health work is being in Java was about 40, the death rate about 18, and the developed on the pattern of work known as the infant mortality rate 150. " Bandung Plan ".This is a combined curative and In 1956 there were 533 government -owned hospitals, preventive programme of health work under one general and specialized, with a bed capacity of 50 262, 224 FIRST REPORT ON THE WORLD HEALTH SITUATION and 176 private hospitals with 17 458 beds.This in 1954 but increased again to 194, with 10 deaths, total of 67 720 hospital beds represents approxi- in 1956. mately 0.9 beds per1000 population.Beds are Between 1946 and 1949 antimalaria work had been distributed as follows : general and auxiliary, 50 732; initiated by the use of residual DDT spraying, and the mental,7660;sanatoria,1748;leprosaria,4907; systematic use of DDT for indoor spraying was begun ophthalmological,775;maternity,1658;venereal in 1950.From 1951 to the present time this work diseases, 240.There is still a serious lack of nurses, has steadily expanded and the population covered which hampers expansion of the hospital service. has increased from 140 000 in 1951 to 4.9 million Medical care in general can also be expanded by in 1954 and 17.8 million in 1957. A mass campaign increasing the number of out -patient clinics, of which for yaws control started in 1950 and is continuing; there were 3153 at the end of 1954, 245 of them being it is planned to complete the programme by 1965. privately owned. In 1956, 5234 patients were under hospital treatment A Central Medical Laboratory was set up in 1888; for leprosy in the 55 leprosaria, leprosy settlements other laboratories have been added since, including a and villages; over 5500 more were receiving treatment number of specialized units for malaria, etc.There at out -patient clinics or were isolated at home. A are now 16 laboratories, including the special institutes, five -year plan has been worked out which includes and it is planned to establish at least one laboratory registration of cases, repair and construction of build- for each province and later to install regency labo- ings for treatment of leprosy cases, training of medical ratories in connexion with auxiliary hospitals or health and para- medical personnel, and research. centres. Tuberculosis is endemic and appears to have ex- There are six medical schools and two dental tended in recent years.There are now 19 hospitals schoolsinIndonesia.The medical facultiesare for tuberculosis patients, and it is planned to increase attached to the universities of Bukittinggi, Djakarta, the number of tuberculosis centres, which will form Jokjakarta, Makassar, Medan and Surabaya, gradu- the most important links in the chain of control. ating a total of 200 students each year.The two dental Tuberculosis control work includes BCG vaccination schools are at Surabaya and Jokjakarta, each gra- programmes and will in the long run lead to a mass duating 20 dental surgeons a year. x -ray control programme.In 1954, 81 903 persons Since 1954 considerable development has taken were vaccinated with BCG. place in training activities for many types of auxiliary Health education of the public is fully appreciated health personnel.Refresher courses are held for in Indonesia and work has been in progress since midwives, and six additional courses were started 1924, when an anti -hookworm campaign was de- in1954 for assistant midwives. A home visitor veloped.Since that time various health demonstrations course was begun in Sulawesi in 1955, and another have been given, and a training school for health in South Sumatra in 1956.In 1956 a public health educators and village hygienists was set up in 1935. nursing school was opened in Djakarta, and the num- Unfortunately much of this work was ruined by the ber of courses for nurses was increased in the provinces. war and has had to be built up again.There is a In 1954 the medical and para- medical personnel in long- standing tradition in Indonesia that the com- Indonesia were reported as follows: 1504 doctors, munity, especially in rural areas,should take an 260 dentists, 108 pharmacists, 1174 assistant phar- active part in conducting its own affairs, including macists,1838midwives, 727 nurses (newtype), community health work.Many villages select their 6000 nurses (old type), 64 analysts,14 dietitians, own rural health worker and support his activities. 3200 other para- medical personnel. In addition there are: (a) a number of child welfare Of the notifiable diseases, the highest case and death foundations in many towns and rural areas providing rates relate to typhoid, bacillary dysentry, smallpox home visitorsattheir own expense;(b)village and plague.In 1956 there were 6106 cases of typhoid health committees inrural areas which organize and 433 deaths; 3330 cases of bacillary dysentery and and sponsor clinics for both preventive and cura- 163 deaths; 113 cases of plague and 28 deaths; and tive purposes; (c) voluntary agencies which organize two smallpox epidemics in that year brought the small centres for minor ailments only; (d) parent - number of cases to 2817 and the number of deaths teacher associations which carry out active work in to 2078.Diphtheria accounted for 1001 cases and schools to encourage both personal and environ- 168 deaths in the same year.No cases of yellow mental hygiene. fever, cholera, typhus or relapsing fever occurred in The Indonesian Red Cross has first -aid posts all the period under review.In 1953 there were 203 over the country and in some rural areas there are cases of poliomyelitis; the number dropped to 135 village Red Cross associations. SOUTH -EAST ASIA REGION 225
Dental care is provided through 27 dental clinics. vised by midwife -supervisors stationed in the pro- A school dental service has been organized on an vincial health departments. experimental scale at Bandung and Djakarta, and The aim isto establishaltogether 3000 MCH schoolchildren in other places receive attention at centres; at the end of 1956 there were 1650, and by the local dental clinics. the end of 1957 some 1900.The number of technical The Ministry of Health has established a Nutrition staff for these services has also increased considerably, Institute in Djakarta.It has been recognized for a and 905 midwives were engaged in MCH work at long time that the high infant mortality rate is due the end of 1956.Four new auxiliary maternity homes largely to malnutrition, and the number of nutritional have been established, and in the various regencies diseases gives rise to serious problems. efforts are being made to organize school medical Maternal and ohild health is part of the public services. health programme of regencies and sub -districts and According to a survey made by the Ministry of is under the supervision and direction of the regency Health in 1952,it was estimated that more than medical officer, who is assisted by a nurse -midwife half the rural population were using surface water with public health training.The primary unit for for drinking.About one -third obtained their water MCH work in a regency is the village.Here, one from wells, and in several places rain -water was home visitor and one assistant midwife are responsible collected and used.Wells are for the most part of for the work.Their activities are supervised and co- the shallow type and are neither lined nor covered. ordinated at the sub -district level by the nurse -midwife There are practically no pipe -borne water supplies stationed at the sub -district capital, who is responsible in rural areas, but on the estates treated river water is to the regency nurse -midwife.She in turn is super- used to a great extent.
NEPAL
Nepal lies between India and Tibet on the southern slopes of 20 students were sent to Australia, India, the United Kingdom, the Himalayas and includes Mount Everest.The mountains and the United States of America. are barren but there are many fertile valleys.The country has The first railway, narrow gauge, was opened in 1927 and there two main divisions: the Tarai, a broad level strip along the are now several narrow gauge lines in the country.There are southern border; and a great mountainous tract stretching north about 417 kilometres of motor roads.Three airstrips were to the Himalayas.The rainy season is from June to October constructed in 1951 -52, one of them in Katmandu. and the hot weather from April to June.The area is 140 753 square kilometres. Health The population at the 1954 census was 8 431 537, with a Under the Secretary to the Minister of Health, density of 60 per square kilometre.No other vital statistics are available.The indigenous race is Mongol with a consider- Education and Local Self -Government, there are a able admixture of Hindu blood from India.The people were Deputy Secretary for Health and a Director of Health originally divided into many hill clans, one of which, the Gurkha, Services.Under the latter are two deputy directors, became predominant towards the end of the 18th century and one for allopathic medicine and one for ayurvedic has given its name to all.The capital, Katmandu, has a population of about 109 000.The surrounding valley has medicine. No medical officer has yet been designated 450 000 people, including Patan with 105 000 and Bhadgaon for public health work although one has been trained with 93 000.The main occupation is agriculture. for the purpose.There are as yet no trained nurses, The principal articles of export are food grains, jute, timber, but a school of nursing was set up in May 1956.The oilseeds, ghee, potatoes, hides and skins, and cattle.There are latest available figures indicate that12 candidates valuable forests in the southern part of the country. Medicinal herbs grow in the north on the slopes of the Himalayas. are in training and eight more are to be selected New industries are developing, such as jute and sugar mills shortly.A school for health assistants, accommo- and various factories and chemical works.Three hydro- electric dating 20 students, was opened in February 1956. plants were in operation in 1953.The chief imports are textiles, Doctors are trained in the medical schools in India cigarettes, salt, petrol and kerosene, sugar, machinery, boots and shoes, paper, iron and steel.Nepal has good agricultural, and there are a number of students in training at the mineral and water power resources but is still largely undeveloped, present time.Compounders are trained in the Civil with few modern means of transport. A good part of the revenue Medical School at Katmandu with a two -year curri- is now being devoted to development and land reform has culum. begun.Schools and village development centres are also being There are 32 government hospitals in the country, established.In 1954 there were 921 primary schools, with over 26 000 pupils, 399 secondary and technical schools, with including six situated in Katmandu, with a total of 46 000 pupils, and 21 higher schools, with 1316.In 1952 some approximately 600 beds.Many of the sanctioned 226 FIRST REPORT ON THE WORLD HEALTH SITUATION
posts in hospitals for doctors, nurses, compounders into health centres as soon as enough health assistants and dressers are not filled on account of the shortage have been trained. of trained personnel.There are also two govern- In a study based on the information collected from ment dental clinics in Katmandu. 14 Nepal hospitals and dispensaries on their in- patients The Government maintains 20 dispensaries in the and out -patients for the years 1954 and 1955, it is districts beyond the Katmandu Valley.The services revealed that diseases of the digestive system, diseases include immunization and health education through of the eye, inflammation and ulceration of skin, di- a number of compounders who have been given a seases of the ear, dental diseases, malaria, diseases of two -year courseinpublic healthsubjects.They the respiratory system, injuries and diseases of the work in district headquarters towns and their imme- endocrine glands were the leading causes of mor- diate environs.It is proposed during the next five bidity.Among the quarantinable diseases, smallpox years to open 22 additional dispensaries and to and cholera were recorded in the study.Leprosy convert them, together with the existing dispensaries, and tuberculosis are both reported to be prevalent.
PORTUGUESE INDIA
The State of Portuguese India consists of three enclaves on funds allocated to the health services.The proportion the west coast of India -the districts of Goa, Damao and Diu - of the total budget allocated to the health services is lying between latitudes 14° 45' and 20° 45' north and longitudes 70° 52' and 74° 21' east.The total area is 4193 square kilo- 1.29 per cent.This only covers the cost of running metres, of which Goa occupies 3611 square kilometres, Damao the services; expenditure on maintenance and equip- 546, and Diu 36. ment of hospitals and other establishments is met At the 1950 census the total population of Portuguese India from another fund. was 637 591; the distribution by district was: Goa, 547 448; Damao, 69 005; and Diu, 21 138.In 1956 the population was Medical care is provided through hospitals, dis- estimated at 645 639. pensaries, health units, medical stations, and other For administrative purposes, the State of Portuguese India government establishments, or by voluntary institu- is a Portuguese overseas province under the supreme authority tions, which are nearly always subsidized by the State. of a Governor-General. In 1956 there were in Portuguese India three govern- ment general hospitals with surgical and specialized Health units and a total of 300 beds, an infectious diseases The structure of the health services is based on a hospital with 10 beds, a leprosarium with 150 beds, a Decree of 1945, under which the health services in sanatorium (145 beds), and a hospital for mental the Portuguese overseas provinces were reorganized. diseases (110 beds).The general hospital in Goa The central Health Department is in charge of three has 180 beds; those of Damáo and Diu each have sections - medical,pharmaceutical,and adminis- 30 beds and small surgical and maternity units.There trative. are also three hospitals run by voluntary organizations Medical services are provided throughout the terri- with government subsidies, and equipped with surgical tory through 16 district health services, six subsidiary and specialized units;their total bed capacity is district health services, and a port health station at 310 (Ribandar, 130 beds; Margáo, 110; and Mapuca, Mormugao.Local health units, maternal and child 70).Further accommodation isprovided inthe health clinics, and health stations for mine -workers regional medical station at Pondá (12 beds), and are all under the technical supervision of the district 12 nursing homes with a total of 120 -140 beds. and subsidiary district health services.Hospitals, Medical care in hospitals and other government health medical stations, leprosaria, maternity homes, and all establishments is entirely free of charge to the indi- other establishments for in- patient care, are under genous inhabitants and to civil and military officials. the technical direction either of the central Health At the end of 1956 medical and health personnel Department or of the district health services in whose intheterritory(bothgovernmentandprivate) area they are located. consisted of 400 physicians,132 male nurses, 98 The pharmaceutical section is responsible for the female nurses, 119 midwives and 90 pharmacists. supervision of pharmaceutical practice and for the The general health situation in Portuguese India purchase and distribution of drugs and other medical was good during the period under review.No case supplies for the use of the government health services. of cholera was notified, although as a preventive The administrative section is responsible for the measure systematic vaccination is carried out; 21 663 work of the Secretariat and for the administration of cholera vaccinations were performed in 1956.Only SOUTH -EAST ASIA REGION 227 small outbreaks of smallpox occurred, in very limited No special programme of health education as such areas, in 1955 and 1956; smallpox vaccination is has been organized, but the medical staff of the health carried out on a large scale. services give talks on health in schools, factories and The campaign against filariasis includes control at other places where groups of people are brought the larvalstage of the mosquito responsible for together for this purpose. Bancroft's filariasis and treatment of filaria carriers. The town of Goa has been supplied with a new A survey, begun in 1954 in Goa and Reis Magos, is water system aimed at increasing the daily capacity continuing in the town of Diu, where the percentage of 3000 cubicmetres,which was found tobe of microfilariae carriers was found to be 6.8, and insufficient.There are also wells providing water treatment with Hetrazan was given. Ninety -five per for all purposes, and in fact this system is used through- cent. of the insects caught were culicines, which leads out the Province.Piped water -supply systems are to the conclusion that the vector responsible may be at present being installed at Margo and Vasco da Culex fatigans. Gama. A malaria survey was made in the district of Quepem. There is no main drainage in the towns of Portu- Malaria control campaigns were started before 1954 guese India, but it has been made compulsory to install in Old Goa, Canácona and Sanguém.In the main septic tanks in all buildings in urban areas which have urban areas insecticide spraying iscarried out at been constructed, renovated, or repaired since 1940. regular intervals, with beneficial results. No dwellings may be built without prior approval With regard to leprosy,all infectious cases are being given to the plans, which must conform to compulsorily segregated inthe leprosarium.The certain minimum requirements of hygiene and sani- programme of tuberculosis control includes case - tation. finding among relatives of patients.An epidemi- The most important public health needs at the ological survey, with tuberculin -testing,is planned present time are: the provision of safe drinking -water for the near future. in all the main urban areas; the installation of main There are 20 maternal and child health clinics in drainage in the most populous centres (this has already operation in theterritory.Since1954, midwives been planned for Goa); the extension of the malaria appointed to the rural maternal and child health control programme to areas which it has not yet services of the Public Assistance and Welfare Organiza- covered; improvement of medical care services for tion work under the technical direction of the district mine -workers (already planned); and intensification health services.Infant mortality rates during the of the tuberculosis control campaign by building and period under review were as follows: 89.1 in 1954, equipping more dispensaries, obtaining a mobile minia- 98.6 in 1955, and 87.6 in 1956. ture x -ray unit, and carrying out BCG vaccination.
THAILAND
Thailand lies between 5° and 21° north and 97° and 106° east. and Khmers.Bangkok, the capital, had a population of It is bounded on the east, north -east and south -east by Laos and 860 409 at the 1947 census (1958 estimate:1 470 000).The Cambodia, on the south by Malaya and the Gulf of Siam, main occupations are agriculture (9 million workers), manufac- and on the west and north -west by Burma.The country falls ture (200 000), and commerce (700 000). into four natural zones: northern Thailand, which is mountain- The countryisdividedinto71 changwads(provinces), ous and forested; the Khorat Plateau, 150 -450 metres above sea each of which has a governor.Local legislative and executive level and rather barren; central Thailand, a large, well -watered bodies are being established, with functions and modes o and fertile alluvial plain; and southern Thailand, a long penin- election closely modelled on those of the National Assembly. sula which contains tin and wolfram mines and produces rubber The economy of Thailand is almost exclusively agricultural; and some rice. the country's prosperity depends on its chief commodity, rice, The climate is very humid.The wet season runs from May for the production of which its climate and conditions are very to October, with temperature ranges from 24° to 32° C during favourable.Fishing and animal husbandry are also important, the day.The north -eastern monsoon begins in November, and tin, rubber, and teak are produced in quantity.The prin- after which it is cooler.After February the heat in the interior cipal imports are textiles, machinery, vehicles, chemicals and gradually increases and may reach 38° C.The climate varies petroleum products. according to the region, altitude and distance from the sea. At the end of 1957 there were 3490 kilometres of railways, The total area is 514 000 square kilometres. 7449 kilometres of state highways and 1693 kilometres of pro- The population at the 1947 census was 17 442 689 (1958 vincial highways open to traffic, and over 5772 kilometres estimate: 23 600 000), with a density of 46 per square kilometre. ofstatehighwaysand 1930kilometresofprovincial Approximately 90 per cent. of the population live in rural areas. highways were under construction.There isone national The people are not wholly unmixed Thai stock: there has been air transport company, and many international air lines call at an intermingling with Chinese and Burmese, and with Mons Bangkok. 228 FIRST REPORT ON THE WORLD HEALTH SITUATION
Health The Department of Health has a number of divi- sions,includingvitalstatistics,health education, In 1888 the Department of Medical Care was communicable diseases, tuberculosis, malaria -filariasis, established; it was the first institution dealing with leprosy,venerealdiseases,yaws,nutrition,rural the health of the Thai people.Its main functions health,sanitaryengineering,schoolhealthand were to control the hospitals and to carry out vaccina- maternal and child welfare.Furthermore, in the tion.The first public health law was promulgated provincial health administration there are 71 offices in1897, requiring the appointment of a medical of provincial health officers, and a number of district officer of health and a sanitary engineer.Its duties health officers. were transferred to the Ministry of the Interior in The Division of Vital Statistics was created in 1936. 1908.In1909sanitary boards were created for Since that date it has been gradually improving and towns and communities.The supervision of these extending the scope of its work, and the accuracy boards was entrusted to the newly formed Medical of its data.The most recent rates are as follows: Department in 1915.In 1918 the Department of 1953 1954 1955 1956 Public Health was established by Royal Decree, and Birth rate 31.5 34.8 35.0 38.2 was expanded in 1942 to become the Ministry of Death rate 9.5 9.8 9.4 10.0 Infant mortality rate . . 64.9 63.6 56.1 55.3 Public Health. The Ministry of Public Health has the following The maternal mortality rate has been falling year offices: Office of the Secretary to the Minister; Office by year, but still stood at 5.5 in 1955.The expecta- of the Under -Secretary of State; Department of tion of life at birth rose from 31.6 for males and Medical Services; Department of Medical Sciences; 37.4 for females in 1929 to 48.5 and 51.4 respect- Department of University of Medical Sciences; and ively in 1947.The leading causes of death, as re- Department of Health.In addition to these there ported for 1955 are, in order of importance, certain are now the Committee for Medical Research, the diseases of early infancy, malaria and tuberculosis. government pharmaceuticallaboratories, andthe The cardiovascular diseases also figure on the list. National Nutrition Committee. The estimated numbers of health and medical The Medical Council, and committees dealing with personnel in Thailand are as follows: physicians, 3031; the control and sale of drugs, the quality of food, dental surgeons, 205; pharmacists, 771; nurse mid- medical registration, international health and nursing, wives, 4017; nurses, 4296; midwives,138.There have been placed directly under the Under - Secretary arealso64 dental hygienists and 2105 auxiliary of State. midwives. The Department of Medical Services includes the The Department of Medical Services deals mainly divisions of mental hospitals, provincial hospitals and with the construction and supervision of hospitals several separate units.The Medical Sciences Depart- throughout the country.From 1949 to the end of ment covers medical research, diagnostic laboratories, 1957, 72 provincial hospitals, five mental hospitals and drug control, and the analysis of food and drugs. one neuropsychiatric unit had been set up.In addi- The University of Medical Sciences is composed of tion, hospitals for women and children, a priest's the various schools of medicine (Siriraj and Chula - hospital and 1 general hospital (Lert Sinn) make a longkorn)andschoolsofdentistry,pharmacy, total of 85 hospitals in the Department of Medical public health, public health nursing, nursing and Services, and more are under construction.The midwifery,sanitaryscience,dentalhygieneand total number of beds in these hospitalsis4000. medical technology. In addition there are 19 municipal hospitals with a The University of Medical Sciences was founded total of 1466 beds, and two Red Cross hospitals in 1943, bringing together under the control of the with 600 beds.The hospitals in Bangkok under the Ministry of Health the whole of medicine and the jurisdiction of the Department are used as post- allied sciences.Since 1943 there have been a number graduate training centres for provincial doctors and of changes in organization: the Faculty of Veterinary nurses.The Women's Hospital was opened in 1951 Sciences was transferred to the Agricultural Uni- with a bed capacity of 150.As time went on, the versity (Kasetrasart), and a second medical school needs, especially of young children, led to the construc- was created at Chulalongkorn Hospital, to meet the tion of additional departments. A separate wing ever -increasing demand for doctors. A new school for sick children, containing 200 beds, was set up of public health was opened in1948,offering a in 1954 and now there are over 13 different depart- one -year course to medical graduates for the degree mental activities, including a blood bank and depart- of Master of Public Health. ments of gynaecology, surgery and radiology, as well SOUTH -EAST ASIA REGION 229 as a cancer clinic.Approximately 17 per cent. of Thonburi the school population under supervision is all babies in the Bangkok area are born in the Women's about 200 000.At the provincial level the school Hospital. services are under the health officers, and attempts Theschoolofnursing,whicheducatesover are being made to extend them to rural areas.Mobile 400 student nurses from the various provinces,is units have been started and are attached to the pro- an essential part of the Women's Hospital.Each vinces on a regional basis.Each unit consists of a year it turns out 100 graduate nurses. physician, three nurses and one or two dental hygienists. In order to improve and expand the rural health The school health division assists the Ministry of Edu- services the Department is setting up a number of cation in health education in schools.Health educa- health centres every year.These are of three different tion has always been a part of the health work of the types: country and at present the subject is being introduced (1) The first -class health centre with a minimum into the training courses for different categories of health of 10 beds and staffed by doctor, nurse midwife, workers.Effortsare also made tobring health midwife and sanitarian; education into the community development projects so that it may reach village communities, schools (2) The second -class centre with, as a minimum, and health centres. a sanitarian and a midwife; Various training courses are offered by the Health (3) A midwifery centre with a midwife in attendance. Department for their own staff.Up to 1955 more than 4000 health workers had been trained. A It is estimated that each centre serves a popula- permanent health demonstration and training centre tion of about 5000.The provincial health officers, was established in 1951 at Cholburi. who are appointed by the Health Department, also An extensive programme of DDT spraying against supervise the activities of the health centres.One of malaria has now been in progress since 1949, and the important and recent rural health activitiesis the results are reported to be highly satisfactory. the development, as a working demonstration, of a Filariasis is restricted to the fiat, low -lying eastern modern health programme based on community coastal belt, and the work of eradication has been organization and active citizen participation.De- placed in the hands of the malaria control programme. monstration villages have been set up in many pro- Yaws is prevalent in about 40 provinces of the King- vinces.The local health committee, elected from dom, and affects about one -tenth of the population. villageofficialsand lay people,takes charge of A scheme of control is now in operation.Similar environmental sanitation under the supervisionof action is being taken in the control of leprosy and the provincial health officer.At the end of 1956 venereal disease. there were 105 first -class and 655 second -class health The tuberculosis hospital, situated close to Bangkok, centres and 153 midwifery centres. was the first of its kind in the country.When it Training courses for midwives are given annually, was established in 1941, it had 25 beds, later increased and at present 1194 midwives are employed by the to 50.The tuberculosis control service of Thailand health department.On account of the shortage of started with the opening of a chest clinic in Bangkok qualified nurses,especially inruralareas,grants in1949,asa demonstration centre for modern have been given to young women to enable them methods of diagnosis and treatment.Shortly after- to study nursing and public health.It is expected wards the hospital was added to the service and a that 60 nurseswill graduateannually.Training surgical unit was set up. A tuberculin- testing and courses for mohtamyae (indigenous midwives) have BCG campaign was begun in1951and greatly also been started.Two mobile units have been set extended two years later. up to help mothers and children in isolated areas Rabies is a serious problem in Thailand, as there which cannot be reached by midwives stationed at are about 200 deaths a year from this cause. A permanent health centres.It is hoped ultimately to rabies control law, enacted in 1954, required owners assign one mobile unit to each province. to have their pets immunized. A large number of The school health serviceis under the general stray dogs are being destroyed each year, and there supervision of the Department of Health, and the work should be a considerable reduction of cases in the includes examination for the detection of disease, near future. physical and mental defects, and psychological disor- During the years 1951 -55 a general survey was ders, and general supervision of growth and develop- made to determine the incidence of parasitic infesta- ment.The school health division serves about 200 tions in rural areas, with the result that greater primary and secondary schools.In Bangkok and emphasis is being laid on environmental sanitation. 230 FIRST REPORT ON THE WORLD HEALTH SITUATION
The major epidemic diseases are now being brought water research has been created, and studies are being steadily under control. made for the protection of supplies with the object The aimsof environmentalsanitationareto of introducing piped water systems where possible. improve water supply and excreta and refuse disposal The Department of Medical Sciences has, as its in rural areas.Most of the rural population make main object, the promotion of research.It deals use of surface water for drinking, but rain -water especially with tropical diseases and also has a wide isalso used.Earthenware jars are sold in large interest in food and drug analysis.Under its control quantities to encourage the practice of collecting and a number of diagnosticlaboratorieshave been storing rain -water. A co- ordination board for ground- organized. EUROPEAN REGION FIG. 9.EUROPEAN REGION
° : DENPAARK: `' 1:::77. Copenhagen IG51SS74 :
...... YUGOSLAVIA AUSTRIA Austria lies in the heart of Europe, bounded by Germany, health ministry, the Office of Public Health was Czechoslovakia, Hungary, Yugoslavia, Italy and Switzerland. established in the Ministry of Social Administration. Itsarea -83 850 square kilometres- includes much of the Eastern Alps and, on the northern borders, the Bohemian Massif. Today the principal health authority of Austria is Ninety -two per cent. of the country is mountainous and only the Federal Ministry of Social Administration.There 4.5 per cent. is true plain, mainly along the Danube.Forests is a Director- General of Public Health, and a number cover about 40 per cent. of the productive area.The climate is of specialists deal with the different sections, including predominantly mountain and semi- continental. The last census year was 1951; at that time the population socialinsuranceandsocialwelfare. A Central was just under seven million, of whom 1 766 102 lived in Vienna. Sanitary Advisory Council has been established con- Approximately half the population are still settled in rural areas. sisting of 23 regular and five extraordinary members. The people are predominantly of Alpine stock and are German - There are other advisory councils -e.g., for the phar- speaking.The educational level is high. There are nine provinces (Lander), each of which has an macopoeia and for the issue of a food control code. elected Assembly. The main federal institutes are as follows: six bac- Agriculture is still the most important activity, but there are teriological and serological institutes, in Vienna, Linz, also big heavy industries and mining.There is a great variety Graz, Salzburg, Klagenfurt and Innsbruck; three of mineral wealth.Hydro -electric power is now being developed institutes for food control, in Vienna (with a branch in and the potential supply is large.Forestry is an important industrial occupation.The natural food production is not Linz), Graz and Innsbruck; one chemico- pharma- enough to support the population.Austria is one of the world's ceutical institute, in Vienna; one institute for biological largest producers of high grade magnesite. products, in Vienna (producing smallpox and BCG The Danube carries a great deal of traffic, but there are vaccine); one institute for serum control, in Vienna; also 30 722 kilometres of good roads and 6000 kilometres of State railways.The main centres of communication- Vienna, one institute for rabies control and the production of Graz and Innsbruck -are well served by airlines. rabies vaccine, in Vienna; one institute for the produc- The social security schemes, which have been very fully tion of therapeutic sera, in Vienna (producing tetanus organized in Austria, cover 80 per cent. of the population. serum, diphtheria serum,etc.);one institutefor experimental pharmacology and balneology in Vienna. Health In addition to these, there are also three State authorized institutes for food control in the Lander, The early health regulations, in force up to the end at Salzburg, Klagenfurt and Bregenz. of the 17th century, dealt mainly with the control of The Federal Ministry does not exercise direct powers epidemic diseases, the rights and duties of physicians in relation to the sanitary services of communities, and pharmacists and the provision of drugs.During hospitals, health resorts, etc., as in this sphere the the 18th century, owing to epidemics of plague, strict nine Lander are competent.The chief of each Land measures of quarantine were introduced.Provision is bound by the directions of the Federal Ministry but was made for coroners' inquests; the first steps in the has a supervising health officer under his direction medical care of the poor were undertaken; and with the necessary specialists,exercising executive measures were introduced for the control of smallpox. powers.In each Land there is a sanitary advisory In 1770, various sanitary rules were codified under a council. general sanitary law which was the basis of the whole The local district authorities which represent the health administration.By the end of the 18th century lowest administrative levels are subordinated to the health officers were established by nearly every local chief of the Land.Each of these district authorities authority.Smallpox vaccination was introduced early has a health officer and has established centres for in the 19th century and several hospitals were founded, maternal and child health, tuberculosis, school dental including maternity and mental hospitals.Schools service and general health examinations.There are for midwives were also founded and in 1850 a also centres for mental health, the care of cripples and medical committee was established by every regional of the aged, and all these institutions are open to the authority. general public.The cost of medical treatment of all The health administration was reorganized under an kinds, including hospital care, is borne by social Empire Sanitary Code in 1870, providing for three insurance institutes.Most of the population are levels -a health department of the Ministry of Internal insured but there is also a service for the poor who are Affairs, regional authorities and local authorities. not insured under the social welfare scheme.The Post -graduate education for health officers was or- district authorities supervise the communities in carry- ganized officially in 1872.In 1919, after a temporary ing out the powers of either the Federal Republic or
- 233 - 234 FIRST REPORT ON THE WORLD HEALTH SITUATION the Lander. Each community is obliged by law to to take a post -graduate course of one year ending engage a physician but several communities may com- with a special examination. bine for the purpose.It is the duty of the community The control of communicable diseases is based on a physician to assist the mayor by advising on local law of 1950 and the regulations issued under it.There healthactivities.The percentage of the national is a continuous programme of vaccination against budget spent on the health service was 0.5 in 1954 diphtheria, tetanus and whooping -cough.Legal pro- and 1955 and 0.4 in 1956. visionisalso made for BCG vaccination.There There is a central office for statistics, to which the are a great many medical diagnostic laboratories local health officers send in all statistical material. provided by universities, hospitals, social insurance There are no local statistical departments.The birth, companies, etc. death and infant mortality rates for 1954 were 14.9, In Austria, where the idea of rehabilitation was 12.1 and 48.3 respectively. developed as early as 1915 by Spitzy and extended There are 296 hospitals with about 67 000 beds. in 1916 by Boehler, there are today four main centres Among these are 181 general hospitals, including the of rehabilitation: at Stollhof, with 90 beds, at Tobelbad university hospitals in Vienna, Graz and Innsbruck, near Graz with 180 beds, at Wiener Neustadt and at which take patients of every age without regard to the Hermagor.These centres work in close co- operation type of disease.In addition there are nine special with the accident hospitals.After -care is carried out hospitals for children, 24 for tuberculosis (with an either in the hospitals, in the health centres or in the additional four for children), one special hospital for physicians' surgeries.Some after -care is also carried dermatology and venereal disease, 11 for orthopaedic out in convalescent homes or at health resorts under or accident surgery, and 17 for neurology and psy- the social insurance scheme. chiatry.There are also 12 convalescent homes, 21 The dental service is provided by the dentists either charitable institutions for incurables and 16 special at their own offices or at health centres.There is a lying -in hospitals. special school dental service. In the provision of domiciliary medical care the More than 1500 maternal and child health centres arrangement is that the physician may be consulted have been set up, most of them under the direction in his office or at the patient's home.The fee is of the public healthservice. A few have been paid by the patient.If the patient is insured and provided by the social insurance scheme.Maternity the physician has a contract, the fee is paid by the and children's hospitals also give maternal and child social insurance scheme.In the case of poor patients health services.The school health service is organized who are not insured the payment is made by the local by the Board of Education but not so far on a co- welfare department.Health centres, established under ordinated plan in the various Lander.Reorganization the social insurance scheme, are known as ambulatories is in progress to make the service uniform through and are open to all the insured population.These the country. health centres offer services in the whole range of Health education of the public has not so far been medicine, including x -ray and laboratory work. organized on any general plan.Preparatory work has In 1953 there were 13 000 physicians, including 5200 now been carried out in co- operation with the Ministry in general practice, 2600 specialists and 1300 dental of Education and local health officers, and some specialists;therest were hospital physicians.In progress is being made. addition to the 1300 dental specialists there are still Occupational health services are carried out by the about 2400 ungraduated dentists in Austria.The Factory Inspectorate, supervised by a central depart- figures in the nursing profession are 14 800 nurses and ment at the Federal Ministry for Social Administration. 2700 midwives. There is special industrial legislation regulating the Physicians and pharmacists are educated at the supervision of workers and preventive services in three universities of Vienna, Graz and Innsbruck. relation to activities handling lead, benzol, silica, and Midwives receive their training at six special Federal so on. A list of prescribed occupational diseases re- schools supervised directly by the central Ministry. cognized by social insurance is published under the Dentists are trained at a special institute, and there general social insurance law.In addition, an Austrian are schools for nurses' training.At the universities Society of Occupational Medicine, an organization for there are post -graduate courses for dental specialists the prevention of silicosis and other bodies, such as the lasting two years.All physicians must undergo Accident Insurance Institution, all deal with occupa- three years' post -graduate training at a hospital before tional health.Special services for the chronic sick receiving licence to practice; for medical specialists are provided for limited groups, such as clinics for this period lasts for six years.Health officers have diabetics,localcentresfortuberculosispatients, EUROPEAN REGION 235
advisory services for cripples,etc.In some cities In the larger cities the public health service also. there are special advisory centres for chronic disease provides consultant clinics for mental disorder and, under the public health service.Various communities in some cases, epilepsy.The Austrian regulations of have set up establishments for the home care of the 1916 for hospital care are very advanced.Mental aged; the larger ones are linked with special hospital hospitals are open to voluntary patients as well as to departments. those certified by a court of justice. The nutritional state of the population is satisfactory. Austria's water supply is taken mainly from pro- Food production and marketing are controlled by the tected wells or ground -water springs.Most of the special department and the six institutes for food larger towns are equipped with a central water -supply control already mentioned.Special standards have system.The great majority of the towns also have been set up and a new edition of the food code has a sewage -disposal plant and schemes must be approved recently been prepared. by the health authority to avoid water pollution.
BELGIUM
Belgium is bounded by France, Luxembourg, Germany and secretariat, which has supreme administrative autho- the Netherlands.Its western coastline is on the North Sea. rity and includes general and research services, the The area is 30 507 square kilometres, and the climate is west maritime.The country has two main physical regions -the Ministry comprises the following six divisions, of northern plains and the southern plateau. which five are directly concerned with public health: At the end of 1956, the population was 8 951 443, with a (1) The Public Health Division, including public density of 293 per square kilometre. There are two main ethnic groups -Walloons, who are French -speaking, and Flemish, health inspection (established in 1845 and strengthened whose language is closely akin to Dutch.The general educa- in 1911); over -all control of laboratories (established tional level is high. in 1945, and incorporating the Institute of Hygiene For administrative purposes, Belgium is divided into nine and Epidemiology, which was set up in 1951, and provinces and 2666 communes, which are to a great extent autonomous. various laboratories in the provinces); food control Although Belgium is a very highly industrialized country, (established in 1891); control of pharmacies (set up industrial development has not taken place at the expense of in1893); the public health works administration agriculture; the two are closely linked in the national economy. (successor to the public health works inspectorate In 1956 the national per capita income amounted to 44 000 instituted in 1903); co- ordination of health establish- Belgian francs (US $880). ments (1947); and meat inspection and control (1945). Health (2)The Social Medicine Division, of which the most important functions include the control of social Although public health inspection was instituted in diseases and the various branches of preventive medi- 1845, State concern with health problems as a whole cine, and which isresponsible for co- ordinating, was relatively slow in developing.It is for this reason supervising and subsidizing the activities of numerous that many of the public health services are in the voluntary organizations.One of the chief activities charge of the communal authorities, and that many of this Division is to organize a network of integrated health problems of social importance, such as tuber- health centres, of which 40 are at present functioning culosis, venereal diseases, cancer, alcoholism, mental and 40 more are in the process of being established. diseases, and even originally child welfare, were first The Division is also responsible for training schools dealt with by private organizations; it was many years for auxiliary health personnel of all kinds (nurses, before these organizations received financial assistance physiotherapists, infant welfare workers, and others). or even, in some cases, legal recognition from the State. The same was true of the mutual aid societies for relief (3)The Welfare Division, which is responsible for in case of sickness.Private initiative continues to the co- ordinating the local public welfare committees and present day to play an important part in the country's for administering the special welfare fund through health programme, and this sometimes raises certain which the State assists the needy by bearing the cost problems of organization and co- ordination. of treatment of certain long -term diseases such as The Ministry of Public Health was founded in 1936; tuberculosis, cancer and mental diseases. its scope was widened to cover family problems, and (4)The Housing and Family Welfare Division, from then on itstitle became Ministry of Public which works in close contact with a number of para- Health and Family Welfare.Apart from its general governmental organizations on housing problems, and 236 FIRST REPORT ON THE WORLD HEALTH SITUATION stimulates the training of family welfare workers, or more cemeteries in the locality.Apart from these providing facilities for families- particularly in case minimum legal requirements, many communes have of sickness -to take advantage of the services of these organized other important services, such as health auxiliary workers. offices, food control services, school clinics, health (5) The Physical Education and Sports Division, centres, and so forth. A continuous policy of fostering which works through another para- governmental the association of communes has produced good organization -the National Institute of Physical Edu- results, particularly with regard to drinking -water cation and Sports, which was set up in 1956. supplies. Vital statistics in 1956 were as follows : birth rate, (6) The sixth division, which may be mentioned 16.78; death rate, 12.07; infant mortality rate, 39.0. in passing, is responsible primarily for dealing with The health statistics section of the Ministry of Public people who have suffered war damage. Health and Family Welfare periodically undertakes Three other Ministries are concerned with certain special statistical studies on such subject as notifiable aspects of public health work: (a) the Ministry of diseases, various aspects of tuberculosis prevention, Labour and Social Welfare, through its services for activities of the Department and of the bodies which it medical inspection of workers, technical and chemical subsidizes in the matter of housing, the health care of inspection of working conditions, the Welfare Fund government officials, of schoolchildren, and of work- for victims of occupational diseases, the service for the ing adolescents, and on causes of death, etc. physically handicapped, and the national sickness and The practice of medicine is free, whether in the disability fund created in 1945; (b) the Ministry of doctor's consulting room or in visiting the patient at Agriculture, through its veterinary and stock -breeding home.The patient is also free to choose the hospital sections, and the National Milk Office; (c) the Ministry in which he wishes to be treated, although in the case of National Education, through its divisions of primary of insured personsitmust be an establishment education (which is responsible for the school medical approved by the Ministry of Public Health and Family services), technical education (which includes, in colla- Welfare. boration with the nursing section, responsibility for At the end of 1956 there were the following medical nursing schools), and higher education (which is in and health personnel in Belgium: 10 358 physicians; charge of the medical faculties of Ghent and Liège, and 825 dental licentiates; 606 dentists; 4927 pharmacists; the veterinary schools of Ghent and Cureghem. It may 3779 midwives.There is no permanent record of be mentioned here that Belgium has two other medical nursing personnel, and the only figures which can be faculties -one at the Free University of Brussels and given are the number of nurses of all kinds who the other at the Catholic University of Louvain). qualify annually, including hospital nurses, public Provincial health services cover a wide field, of health nurses and psychiatric nurses; between July which the following are some examples :(a)the 1957 and July 1958 a total of 8800 qualified.Each bacteriologicallaboratoriesoftheprovincesof province has a health inspector (except the provinces Antwerp, Brabant (Pasteur Institute), Hainaut, Liège, of Brabant, Western Flanders and Liège, which each and Namur; in the other provinces bacteriological have two) who is a qualified doctor with an additional analysis is carried out by government laboratories public health degree. under the direct supervision of the laboratories section The national leagues against tuberculosis and ven- in the Ministry of Public Health and Family Welfare, ereal diseases and the national league of Belgium for as mentioned above; (b) the Health Museum of Mons; mental health all have their own dispensaries.There (c) many social health services, among them those of are also dispensaries for general care staffed by one the province of Liège; (d) institutions for physically or more nurses. and mentally handicapped persons and others. Hospitals and clinics are run either by the public Communal autonomy in health matters has from welfare committees or by private bodies such as the beginning been one of the fundamental principles mutual aidsocieties,religiouscommunities,etc. of the country's health organization.The communes They are under the medical control of a section of have indeed a legal obligation to provide the following the Ministry of Public Health and Family Welfare, services : a public welfare committee for the alleviation which also ensures that they conform to the required of poverty and the organization of medical care of the standard with regard to the treatment of insured needy; a school medical service; routine smallpox persons. vaccination; collaboration with the health inspector Preventive measures against communicable diseases for the treatment and prevention of communicable were originally applied only to the " pestilential " or diseases; a communal meat inspection service; and one quarantinable diseases provided for in the international EUROPEAN REGION 237
sanitary conventions, but they were gradually extended, bulletins.Their activities have recently been co- at the national level,to the other communicable ordinated under the direction of the Belgian Red diseases, including tuberculosis and venereal diseases. Cross. Notifiable communicable diseases must be declared For preventive mental health work, there are mental to the health inspector or the burgomaster, and the health clinics in various towns, which are required burgomaster must then take whatever preventive meas- by law to look after such cases as former mental ures are prescribed by the health inspector or the patients, delinquents on conditional release, epileptics, Ministry of Public Health.In the case of tuberculosis, alcoholics and drug addicts.For curative purposes, the declaration is made to the health inspector only; psychiatricinstitutionsprovideatotalof some it is his responsibility to take the necessary preventive 25 000 beds, and there are also 7000 beds for abnormal measures in consultation with thepatient's own cases, 1200 beds for the disabled, and some 2000 for doctor.As far as venereal diseases are concerned, the deaf and dumb, those with impaired vision, and the an anonymous declaration is made to the health in- blind. spector, and the patient is obliged to submit to medical There are many hospices and homes for aged people treatment, which is a State charge.If he fails to do so, in good health, and there is a growing tendency to the consulting physician addresses a nominative decla- establish homes for elderly couples so that their family ration to the health inspector.Smallpox vaccination life is not broken up. was made compulsory by Royal Decree in1946. Chronic and long -term patients were originally cared Considerable publicity is given to the benefits of for in the same units as short -term patients, but vaccination against diphtheria, tetanus, whooping - nowadays chronic cases are accommodated separately. cough and poliomyelitis. There are, for example, some 4800 beds for cases of Maternal and child health services are organized by pulmonary and bone tuberculosis; cancer control the National Children's Society (OEuvre nationale de centres attached to the four universities for the treat- l'Enfance), a government- subsidized body established ment of malignant tumours; and special centres with by law in 1919, and include clinics for pre -natal and iron lungs and physiotherapy equipment for the post -natal consultations, infant welfare, care of pre- treatment of poliomyelitis. mature infants and of children from three to six years, Special rehabilitation services include sanatoria for as well as holiday camps and homes for children of the rehabilitation of tuberculosis patients, and units for weak constitution. poliomyelitis victims, injured persons, alcoholics, and Medical inspection of schoolchildren in kinder- handicapped people of various kinds. garten and primary schools is required by law, and is The Laboratories Section of the Ministry, and its the duty of the communal authorities under the super- Institute of Hygiene and Epidémiology already men- vision of the Ministry of Public Health and Family tioned,includeunitsforbacteriology,virology, Welfare.Treatment of sick children is not generally chemistry and physics, analysis of food, meat and included, but the service covers systematic examina- drugs, and lymph production.The supervision of tion of schoolchildren, preventive measures against the provincial laboratories has been described above communicable diseases, and inspection of school in connexion with provincial health services.The premises.All pupils have health cards.Results of professional staff of this section are doctors of medicine medical examinations are sent to the statistical section and public health, licentiates or doctors of science, oftheMinistryof PublicHealth and Family biologists or pharmacists. Welfare. Food control is mandatory by a law of 1890, and is Health education of the public is carried out in many undertaken by inspectors (who are pharmacists, doc- different ways.Systematic teaching is given in prim- tors of science or agricultural engineers) and wardens. ary schools, teacher -training schools, technical schools The inspector himself makes simple tests on samples, (particularly to future nurses and midwives), and and if they appear suspect sends them either to the schools of higher education (to students who will be central laboratory under the Laboratories Section of in touch with health matters in their professional life). theMinistry orto an approved chemist.Meat Health education in various spheres is also carried out inspectionof animalsslaughteredinBelgiumis by the Ministry of Public Health and Family Welfare, governed by a law passed in 1952.Drugs must by such institutions as the Health Museum in Mons conform to the requirements of the Pharmacopoeia, and the health collections in Ghent and Liège, and which is regularly kept up to date by the Pharma- by certain bodies subsidized by the Ministry.Apart copoeia Commission; supervision is provided through from the usual media, such asposters, pamph- inspectors of pharmacies who visit laboratories and lets, lectures, films, etc., these bodies publish periodical may take samples, which are tested at the drug analysis 238 FIRST REPORT ON THE WORLD HEALTH SITUATION laboratory attached to the Laboratories Section of able either by inter -communal bodies or by the the Ministry. communes individually.In 1954 it was estimated Research is carried out in the universities as part of that about 74 per cent. of the population were provided the teaching programme, and also by such bodies as withsafewater.Many of the communes have the University Foundation and the National Fund main drainage systems, and the disposal of sewage for Scientific Research, both of which help to recruit through water -courses is governed by strict condi- research workers (either full -time or part -time, in tions laid down in a law of 1950 and in various conjunction with a university post), and to provide by -laws. scientific institutions with particularly costly appa- Special measures are taken against air pollution ratus.Very recently a Fund for Medical Scientific (particularly that caused by dangerous or insanitary Research was established with the special task of premises or motor vehicles), jointly by the Ministry encouraging all research which aims at preserving and of Labour, the Ministry of Public Health and Family restoring human health.Research is also undertaken Welfare (through the Institute of Hygiene and Epide- by government and provincial laboratories at the same miology), and the Royal Meteorological Institute. time as routine work, and by the larger medical At the present time special attention is being given to establishments, where it is carried out side by side the pollution of air and water by radioactive waste. with curative services. A recent law in this regard empowers the Ministry of The supply of drinking -water is controlled by the Public Health and Family Welfare to take necessary National Water Supply Company, and is made avail- measures to safeguard the population.
BULGARIA Bulgaria is situated in south -east Europe, separated in the the Ministry of Public Health and Social Welfare north from Romania by the river Danube, and bordering isthe supreme national authority in matters of in the west on Yugoslavia, in the south on Greece and Turkey, and in the east on the Black Sea.In the north is the Danube health; free medical care, both curative and pre- Plain, sloping gently from the Balkan mountains.South of the ventive, is guaranteed to the whole population by a Balkan mountains lies the Thracian Plain, consisting of the Decree of the Praesidium of the National Assembly basin of the Maritsa river.In the south -western part of the issued on 17 March 1951, and is made available country are the Rhodope mountains.The climate is conti- through the vast network of health services covering nental.The total area is 110 900 square kilometres and the population at 31 December 1956 was 7 613 700.According to both urban and rural areas. A characteristic feature the 1956 census, 33.5 per cent. of the population live in urban of these services is their preventive aspect, which districts. includes measures such as mass immunization, medical The country isdivided internally into 12 administrative examinations of workers and schoolchildren, special provinces called okrugs, and the capital Sofia.Okrugs are further divided into counties. care for mothers and infants, ambulatory services for Bulgaria is an industrial and agricultural country ; in the past a large proportion of the population in polyclinics, ten years there have been great advances in industry, as demons- and specialized services for tuberculosis, psychiatric trated by the fact that in 1939 industrial production represented disorders, and a number of other conditions of social 33.8 per cent. of the country's total production, whereas by 1955 it had risen to 69 per cent.New branches of industry importance.The population takes an active part in have been established, such as the metallurgical, electrical, the application of health measures through the standing chemical and petroleum industries, machine construction, etc. committees on health attached to the People's Councils, Agriculture has been mechanized: in 1956, 85 -95 per cent. of the Bulgarian Red Cross, the trade unions and the the agricultural work was done by machines. political organizations. Education in Bulgaria is free of charge, and primary education (up to 14 years of age) is compulsory.According to a report At the regional or local level, public health is made in 1956, there are 20 institutions for higher education, directed by thelocal public health departments including 32 faculties and 150 technical schools.The Bulgarian attached to the executive committees of the People's Academy of Science has eight departments, 39 scientific research Councils, which are responsible for the epidemiological institutes, museums, a botanical and zoological garden, and a staff of 56 academicians, 47 corresponding members, and and health establishments, as well as hospitals and about 650 scientific research workers who are attached to the maternal and child health centres. Academy. Since1944, the scope of hospital services has increasedrapidly.Whereasin1944therewere Health 174 hospitals with 11 082 beds, by 1956 there were The organization of public health in Bulgaria is 424 hospitals with 30 893 beds, and the staff included based upon a number of fundamental principles : 4508 doctors and 914 dentists. EUROPEAN REGION 239
A vast network of health establishments has been underwent courses in health education.Altogether set up since 1951 in rural areas.In 1944 there were 17 960 health posts have been organized in schools. 870 rural health centres.In1956, for the rural In 1956, 131 634 schoolchildren spent their holidays population alone,there were 255 rural hospitals free of charge in summer camps. with 3885 beds, 704 maternity homes with 2224 beds, Workers in industry, transport and building receive and 1677 healthcentres.The trendistowards qualified and specialized medical care, apart from that eliminating the differences in medical care services provided through the general medical service, from between urban and rural populations, and with this centres established in factories and polyclinics. Accord- in view the rural health services are receiving active ing to the terminology used in Bulgaria, there are at assistance from the specialists in district and town present: 41 medical health divisions (these are complete hospitals, who make regular visits to the villages and medical establishments) with 1269 beds; 116 health thus ensure qualified medical care for the inhabitants services with 365 beds; 21 crèches with 880 beds; of rural areas. 26 prophylactoria and night sanatoria with 495 beds. In 1956, medical care was provided by 92 dispensaries Furthermore, 188 rest houses, with 20 926 beds, provi- with 2923 beds, 100 sanatoria and preventoria for ded facilities in 1956 for 218 028 workers to recuperate tuberculosis patients with 8563 beds, and 159 out- from their labours under medical supervision. patient clinics in hospitals and special establishments There are 14 dental clinics in Bulgaria.Preventive for patients suffering from tuberculosis, cancer, infec- dental care of children and treatment of dental diseases tious skin diseases and venereal diseases and mental have met with considerable success;1394 dental disorders.There were nine clinics with 945 beds centres and surgeries have carried out systematic and attachedtomedical researchinstitutes;33bal- large -scale treatment of children and young people. neological institutes and other medical establishments; Topical application of fluoride toteeth has been and 125 communicable disease control centres, which widely used, and in the rural areas alone, the teeth of supervise relevant public health matters with the assis- 143 837 children were treated in this manner in 1956. tance of all the medical establishments of the country. The following table shows the increase in numbers of In 1956 also, general hospitals provided 119 child- medical and health personnel during the past few years : ren's wards with 3250 beds, and 380 obstetrical and 1944 1954 1955 1956 beds, in addition to 3 8 8642 710 maternity clinics and hospitals, with 2655 beds. Dentists 824 1971 1979 2085 There were pre -natal and post -natal clinics in 317 Medical assistants . 826 1037 1283 1560 town centres and 1201 village centres, as well as Midwives 1070 1892 2029 2174 Registered nurses . . . . 372 6942 7796 8574 three children's hospitals with 260 beds, 759 crèches for infants with 20 920 beds, and 16 special homes Sofia and Plovdiv have institutes for higher medical with 1120 beds for mothers and children. studies, that in Sofia including a faculty of medicine, Maternity leave for working mothers has been dentistry and pharmacy.There are also 17 schools increased from 90 to 120 days.Special care is taken fortrainingauxiliaryhealthpersonnel,suchas of expectant mothers who are working; they are medicalassistants,nursesandlaboratorytech- removed from any potentially harmful work and given nicians.University medical education lasts for six other work to do without a decrease in salary.After years; the training of auxiliary health personnel is of delivery, they have two hours' paid leave a day to two or three years' duration. breast -feedtheir babies until the infantiseight All medical establishments and local health author- months old. ities draw up morbidity statistics and keep a record Doctors, dentists and nurses working in kinder- of the state of health of the population in their areas. gartens and schools take the greatest care of pre -school Medical registration of causes of death is compulsory. children and schoolchildren.Teams consisting of a Some vital statistics for the period 1955 -57 are as dentist and a nurse are available for every 1200 school- follows: children, and they are assisted by specialists from the 1955 1956 1957 Population at 31 December7542 3007613 7007688 800 hospitals and polyclinics.Systematic control of the Birth rate 20.4 19.8 18.7 children's health is carried out by medical examinations Live births 20.1 19.5 18.4 once a year, and anthropometrical examinations twice Stillbirths 0.25 0.24 0.21 a year (four times a year in the case of kindergarten Infant mortality rate 82.4 72.0 66.2 children).The Bulgarian Red Cross works in co- Neonatal mortality rate 35.5 32.5 27.4 operation with the medical staff in health education Control of communicable diseases is carried out by of the public.In 1955 alone, 451 847 schoolchildren the concerted efforts of all the health services with the 240 FIRST REPORT ON THE WORLD HEALTH SITUATION participation of the population.The last case of organized on a large scale under the guidance of the smallpox was recorded in 1927.Between 1954 and People's Councils and with the competent assistance of 1957 only one case of rabies has been known; the health authorities.The State makes considerable since 1913 there has been no cholera, and plague is grants for the construction of piped water supplies, completely unknown to the present generation -the drainagesystems and publicbaths.Widespread last case was during the 19th century.Malaria is building of new houses is in progress, and the State steadily decreasing: between 1944 and 1950 there were gives long -term loans to those who wish to build their several thousand cases, whereas in 1956 only 263 cases own homes. were recorded.In 1956, there were 2.6 cases of The Bulgarian Red Cross takes a very active part in poliomyelitis per 100 000 population, 592.6 cases of health work; in the past it was simply a charitable influenza, 330.0 cases of scarlet fever, 8.9 of diphtheria, society, but it is now a country -wide health organiza- 170.9 of whooping- cough, 190.5 of measles, 161.0 of tion, which towards the end of 1957 had a member- infectious hepatitis, and 1.6 of typhus. ship of 840 594.The Bulgarian Red Cross is effective In 1951 the Council of Ministers issued a Decree in developing the health consciousness of the people concerning tuberculosiscontrol.Mass x -ray and and encouraging their participation in public health fluorographicexaminationofthepopulationis activities.In1957alone,278 500peopletook carried out, and BCG vaccination is compulsory; a health course.Groups of the most active workers in by 1956, 2 014 341 people had been vaccinated. Every the Bulgarian Red Cross are connected with medical Koch -positive case is immediately sent to hospital. establishments and give assistance to those in charge Tuberculosis patients receive every facility for free as need may be.The health education meetings treatment anddrugs,notonlyintuberculosis organized by the National Front are also very popular. hospitals and sanatoria, but also for domiciliary Health education work is directed by the National treatment. Health Education Centre and by the health education Throughout the country, the movement to raise the divisions in the health centres of the okrugs and standard of hygiene in both urban and rural areas is counties.
CZECHOSLOVAKIA
Czechoslovakia is in central Europe and is bordered by Ger- rationing system ceased, salaries have increased by more than many, Poland, the Union of Soviet Socialist Republics, Hungary 13.5 per cent., and at the same time the cost of living has dropped and Austria.The country consists on the one hand of the by 16 per cent.The consumption of meat in 1956 was 55 per " Czech provinces " of Bohemia and Moravia, and on the other cent. greater than in 1936, and that of other foodstuffs had also of Slovakia.The total area is128 000 square kilometres. increased considerably: flour by 60 per cent., sugar by 40 per Prague, the capital, is in central Bohemia. cent., vegetables by 60 per cent., eggs by more than 30 per cent., In mid -1958 the population was 13 470 000, with an average and butter by 15 per cent. density of 105 per square kilometre, and was divided almost In the scholastic year 1956 -57, there were 12 445 primary and equally between urban and rural areas.The population of secondary schools in Czechoslovakia, with a total of nearly Prague is about one million. two million pupils.The general educational level of the popula- Czechoslovakia is a Democratic People's Republic; it is a tion is high; more than 20 per cent. have completed primary and unitary State of two nations, the Czechs and the Slovaks, secondary school education, and only 0.5 per cent. have not possessing equalrights.For administrative purposesthe been to school at all.In the academic year 1956 -57, there were country is divided into 19 regions, the populations of which vary also 672 professional schools, with more than 200 000 students, between 340 000 and 1 200 000.The regions are in turn sub- and 40 institutions of higher education, with 106 faculties and divided into districts, with an average of 15 districts in each nearly 78 000 students.There are universities and technical region. colleges in Prague, Plzeií, Hradec Králové, Brno, Olomouc, The majority of the people are engaged in industry and Ostrava, Bratislava and Kosice.There are also six theological trades, which at the 1950 census employed 3 596 357 people, or colleges. 29.1 per cent. of the working population.The number and In 1956, the country possessed 13 168 kilometres of railways, percentage of people engaged in other occupations at that time more than 71 000 kilometres of first -class roads, and nearly were: agriculture, forestry and fishing, 3 076 261 (24.9 per cent.); 50 000 kilometres of second -class roads.There were also commerce and finance, 873 300 (7.1 per cent.); transport, 908 556 480 kilometres of navigable inland waterways, and 1868 kilo- (7.4 per cent.); the building trade, 698 579 (5.7 per cent.). metres of domestic airlines. Industrial production in 1955 showed an increase of 240 per cent. over that of 1929, which was the peak year of pre -war Health production, and has risen continuously since 1945.There is no unemployment in Czechoslovakia.At the end of 1956, 36.7 per The right to health protection is guaranteed by the cent. of all wage -earners were women.Since 1953, when the Constitution, and is ensured by State organization EUROPEAN REGION 241 of health care services, as well as by various legislative The District National Health Establishment groups measures, the most important of which concern the together all health services for the people in the dis- integration of preventive and curative services, the trict concerned, and works through the district hos- organization of sanitary and epidemiological services, pital, which functions as a single organizational unit the provision of treatment at spas, the practice of with the local polyclinic.(In some districts there is medicine and allied professions, the production and only a polyclinic.)Furthermore, each district has supply of drugs, and, finally, the social measures a sanitary -epidemiological unit, a transfusion centre included in the laws on national health insurance and a health education centre.The District Establish- and social security. ment supervises the activities of other health services Since their unification in 1951, all health services within the district, particularly polyclinics, dispensaries are directed by the State Public Health Administra- and medical and nursing posts, whether for the general tion, with the exception of the faculties of medicine population or attached to industrial concerns, as well and pharmacy (which are under the Ministry of as maternal and child health centres, crèches, homes Education and Culture), and the production of medical for infants and children, and rest -homes.Within instruments and appliances(whichisunder the each district, health services are organized on a com- Ministry for Precision Mechanics).At the national munity basis, each community covering about 4250 level, leadership in all matters of health policy is inhabitants, in the charge of a physician, who provides provided by the Ministry of Health, or, in Slovakia, (and in some cases organizes) all medical care for the by the Public Health Commission.(The relationship people of that community and is responsible for their between the Ministry and the Commission islaid health.In factories,there are industrial medical down in the Constitution, which determines the autho- officers with similar functions, responsible for groups rity of the Slovak national bodies, and the Slovak varying between 800 and 1600 workers. Commissioner is bound by the policy directives of Apart from the network of services provided by the the Minister of Health.)Specialized medical officers Regional and District National Health Establishments, or other experts are in charge of the various divisions certain establishments are administered by the central and units of the Ministry ;all important medical authority, such as the treatment centres at spas, re- questions are examined by the Ministry's Scientific searchinstitutes,and institutesfor post -graduate Council, which is made up of the most eminent medical training. representatives of medical science in the country, In 1957, there were altogether in Czechoslovakia and thus ensures that a high scientific level of direction 215 general hospitals, with a total of 95 551 beds, is maintained. or a ratio of 7.1 beds per 1000 inhabitants; a further At the regional and district or municipal level, the 11 020 beds in special units for tuberculosis patients, organization of health care is directed by national and 57 070 beds in other specialized establishments, committees and administered, at regional level, by making an over -all ratio of 12.2 beds per 1000 in- special departments of health, and at district level habitants.There were also 403 regional and district by departments of labour, health and social security. polyclinics, 1564 community dispensaries, 60 industrial Both the regional and the district health services polyclinics, 603 industrial dispensaries, 690 regional are in the charge of medical officers of health, who and district medical posts, and 1013 industrial medical have the backing of an advisory council of experts posts. drawn from the staff of hospitals and other health Such expansion of the health services has required establishments in the area concerned. a considerable increase in the number and quality Health facilities throughout the country are grouped of medical personnel, as well as extension of the into integrated regional and district National Health facilitiesprovided by health establishments.The Establishments.The nucleus of the Regional National great losses suffered during the war, when the medical Health Establishment is the regional hospital, poly- schools were closed, have been made good in a com- clinic,transfusioncentre,sanitary- epidemiological paratively short time.At the end of 1957 the total unit, and health education centre, supported by other number of doctors in the country was 20 607, or one specialized institutions, such as tuberculosis sanatoria, doctor for every 651 inhabitants, and the health psychiatric centres, rehabilitation units, cancer treat- services as a whole (including pharmacies) had a ment centres, and paediatric clinics.The Regional staff of 158 000, of whom 103 000 were professional Establishment supervises the district health services personnel. in the various medical specialties, and also guides A greatdeal of health work is done by the (and to a great extent actually carries out) special Czechoslovak Red Cross, and there has been a striking training of the regional health staff. increase both in the numbers of voluntary health 242 FIRST REPORT ON THE WORLD HEALTH SITUATION workers and in the scope of their work; similar de- paratyphoid fever, 0.4; diphtheria, 0.3; and scarlet velopments have taken place in other organizations fever, 0.0 (four deaths for the whole country during which play an important part in the health protection the year). of the people, particularly the trade union movement. Morbidity rates for communicable diseases in 1957 Medical care (including drugs and curative and were: measles, 475.2; whooping- cough, 397.8; scarlet orthopaedic appliances) is provided free for the great fever, 206.1; infectious hepatitis,184.4; respiratory majority of the population - workers, members of tuberculosis, 174.2; dysentery, 85.8, and poliomyelitis, higheragriculturalco- operatives,officials,office - 8.0. workers, pensioners and their families, and others. Maternal and child health services are provided Certain charges are made to a very small proportion through 2597 infant and child welfare clinics, 285 (less than 8 per cent.) of the population - that is, clinics for women, 1167 day- nurseries, with accom- those engaged in private enterprise -, but the pay- modation for 36 885 infants, 31 night- nurseries, with ments are very much less than the cost of the services 2346 beds for infants up to one year, 68 homes for provided.The children of these people receive free children from one to three years (2832 beds), and medical care of all kinds until the age of one year, 31 children's rest homes, with 3468 beds.School and generally later, and are also entitled to free in- health services cover more than two million children patient care in hospital until the age of 15. attending 19 000 schools, including nursery schools for Institutional care during pregnancy, childbirth and children from three to six years. the post -natal period, as well as treatment of infectious There are nine medical schools in Czechoslovakia, diseases, preventive care and other services, are free. with an average of about 1000 medical graduates All working women are entitled to 18 weeks' maternity each year. leave, with benefits during this period which amount Environmental sanitation is the responsibility of to as much as 90 per cent. of the salary. the communal health services, which are a part of Vital statistics for the years 1954 -57 were as follows: the health and epidemiological care system.The
1954 1955 1956 1957' dwellings of 41 per cent. of the population are con- Birth rate 20.6 20.3 19.8 18.9 nected to water -supply systems, which are submitted Death rate 10.4 9.6 9.6 10.0 to bacteriological analysis at least four times a year, Infant mortality rate . . 37.6 34.1 31.4 33.4 and in some cases daily.The wells which supply Preliminary figures the rest of the population are also controlled regularly by health inspectors.Thirty per cent. of the people The principal causes of death in 1957, and rates are served by a sewage -disposal system, and main per 100 000 inhabitants, were as follows: diseases drainage is installed in all new housing sites.In of the vascular system, 335.6 (of which heart diseases places where the buildings are older, the existing accounted for 275.1); malignant tumours,173.4; systems are being reconstructed. diseases of the nervous system and sense organs, The second five -year plan (1956 -60) includes further 112.0;diseasesof therespiratorysystem,91.0; expansion and improvement of health services, with injuries and poisoning, 67.8; communicable diseases special emphasis on control of infectious diseases, (including tuberculosis and parasitic diseases), 48.7. prevention of disease and injury, and promotion The last- mentioned group included:all forms of of healthy conditions for the growth and development tuberculosis, 36.4; whooping- cough, 1.5; typhoid and of new generations.
DENMARK
Denmark is a kingdom of northern Europe, consisting of the educational level is high.The main occupations are agriculture peninsula of Jutland, several adjacent islands which are closely (employing 518 000), manufacture (590 000), and commerce knit with the mainland, and the outlying island of Bornholm (317 000). in the Baltic, extending from 54° 3' to 57° 45' north and from Administratively, Denmark outside Copenhagen is divided 8° 5' to 15° 12' east.Its former dependencies, which are now into 22 counties, each of which is administered by a governor. part of the country and have a considerable measure of home Further, the county is a municipal division with a county rule,are Greenland and the Faroe Islands.The area of council superintending the rural municipalities (about 1300). Denmark proper is 43 042 square kilometres.The surface is There are 89 urban municipalities, each with a mayor and a town uniformly low, and the climate is semi -continental. council.Rural and urban councils are electeddirectby The population at the 1955 census was 4 448 401, with a universal suffrage.Copenhagen forms a district by itself and density of 103 per square kilometre; 69 per cent. were urban. has its own form of administration.Production is normally in The people are almost entirely Scandinavian.The general the hands of private enterprise.The chief exports are live EUROPEAN REGION 243 animals and meat, dairy produce and machinery.The principal ing an extension of workmen's compensation and the imports include fuels and lubricants, metals and manufactured development of a system of industrial medical officers. goods, textiles and machinery. Elementary education has been compulsory since 1814.The One of the remaining problems of the health University of Copenhagen has about 5000 students and the system is now the establishment of the greatest University of Aarhus, opened in 1933, has about 1800 students. possible collaboration between the general practi- At the end of 1955, Denmark had nearly 1.8 million registered tioner and the hospital. tonsof shipping. Copenhagen, Aalborg -Norre,Sundby, Esjberg, and Aarhus are the chief ports.There were about The Danish health system isa combination of 12 000 kilometres of roads and town streets, and 46 000 kilo- medical care, preventive medicine and health promo- metres of byways.Railways extend nearly 5000 kilometres, tion, administered partly by the State and partly by of which over half belong to the State.The country is well local authorities.The Ministry of the Interior is served by international airlines. In 1954, nearly 3 million people were covered for sickness and responsible for the treatment of the sick and pro- maternity benefits.The Social Reform Acts of 1933 included phylactic measures against disease, as well as pharma- also public assistance and legislation dealing with unemploy- ceutical and environmental services.The care of ment and accident insurance.According to an Act of 1956, the aged, the crippled, and those who are suffering every person who has completed his 67th year is entitled to a from long -term sickness is under the Ministry for minimum pension, regardless of his economic conditions.Old - age pensions beyond this minimum are received by persons below Social Affairs, which supervises sickness insurance a certain incomelevel. and industrial hygiene.The education of doctors, dentists and other professional workers, as well as Health the school medical service,falls within the scope of the Ministry of Education.There are possible Denmark acquired its first supreme medical board, drawbacks to this separation of duties but they are the Collegium Medicum, in 1740, and the present counteracted by the fact that the National Health organization of the central health authority dates Servicestandsoutsidethecentral administration from an Act of 1909 creating the National Health proper but co- ordinates the work of all the ministries Service.Its aim was not only to advise the local concerned with health.Its functions are threefold: authorities butalsotoinitiatereforms and ad- advisory, supervisory and administrative.Its most vances in the health services.The Act was revised important function is as an advisory body to the and brought up to date in1932.The status of central administration and to the communal councils. physicians and pharmacists has been established by It must preserve close contact with the actual health law since as early as 1672, and the first law relating conditions of the country and see that laws and to epidemics was passed in1782, followed by a regulations are observed.The National Health Ser- series of enactments, with the introduction of com- vice may also submit suggestions for improvement pulsory vaccination against smallpox in 1810.The in public health, and one of its duties is to organize Hospital Act of 1806 laid on the local authorities health education by means of publications, lectures, etc. the duty of building and maintaining asuitable The National Health Service is the chief supervisor number of hospitals.With the advances in bacter- of hospitals (public and private), nursing homes, iology at the end of the last century, new demands children's homes, homes for the aged, and indeed were made on the hospital resources. A system of all premises which are subject to health regulations. health insurance founded in 1892 provided for labora- Plans for the erection of hospitals and for any sub- tory services, and hospitals were enlarged and moder- stantial alterations to them must be submitted to nized and new ones were built.The first Act in a the Health Service.All professional workers in this campaign against tuberculosis was passed in 1905 and sphere are under the National Health Service as regards sanatoria were established.During the past quarter their professional duties and they can be required of a century the hospital system has been constantly to send notifications and reports.The same applies adapted to the demands of new methods of medical to all proprietors of chemists' shops.The Health treatment.Sickness insurance has been revised and Service also authorizes physicians, dentists, midwives brought up to date. and nurses to engage in practice.Administratively it During thesame periodpreventivelegislation comes under the Ministry of the Interior, which is res- began to come into its own, together with the social ponsible for its annual budget, and the health officers and medical care activities.This applied especially work directly under the National Health Service. to the supervision of the health of expectant mothers In every county there is a county health officer and and of children up to their fifteenth year.At the two or three district health officers, all of whom are same time industrial hygiene was growing rapidly physicians who have taken a special course in public and a revision of the existing laws took place, includ- healthwork.Thehealthofficersrepresentthe 244 FIRST REPORT ON THE WORLD HEALTH SITUATION
National Service vis -à -vis the local authorities, and during the period under review, and the amounts within his own district each one is engaged in advisory, spent on benefits (medical treatment, medicine, daily supervisory and administrative work, similar to that cash benefit, and reimbursement of hospital expenses) : at the national level.The municipal councils elect 1954 1955 1956 health commissions which deal withallmatters Number of active concerning drinking- water, sewage, foodstuffs, dwell- members . . . 2 858097 2891951 2901164 Expenditure on ings, etc.In a number of larger towns there is a sickness benefit Kr.208 000 000 223040000 236610000 special health police under the police force to assist (US $30 114377) (US $32 291878) (US $34 256551) the commission.The health commissions also receive assistance from veterinary surgeons in connexion The payment by the health insurance funds for with meat and milk control.An epidemic commission hospital care of their active members averages about takes action against local outbreaks of disease. 10 per cent. only of the actual cost, the remainder The hospitals are maintained and run mainly by being paid by the central and local government. the county councils and the town councils, although Members of the public health insurance are as a some are owned and run by the State, such as the rule covered also by disablement insurance. university hospital in Copenhagen and most of the TheDisablementInsuranceFund,established mental hospitals.In some cases the State finances under the disablement insurance legislation, grants special departments; there are, for example, three of sickness benefit to a certain extent, provided the these for neurology attached to municipal hospitals, benefit may contribute to preserve or improve the and their departments cover a district of such great earning capacity of the person concerned. size that it is far beyond the scope of the smaller Active members of the health insurance funds who municipalunits.The hospitalsare run with a are covered by the Industrial Injuries Insurance Act, regularly employedstaff.The healthauthorities and who are in need of sickness benefit owing to feel that in the future the research department of an industrial injury or an occupational disease, are hospitals should be available for medical practitioners eligiblefor benefits under the Industrial Injuries both in and out of the hospital and that in this way Insurance Act to the extent to which such benefit one of the most important gaps between the hospital cannot be paid by the health insurance.If, as an and the general practitioner will be bridged.As a exception, the injured person is not a member of a result of specialization in the larger hospitals, there health insurance fund, assistance is paid under the is a trend towards using smaller units for after -care National Assistance Act on the basis of financial need. as this saves the great cost of keeping patients in The steady growth of the health services in Denmark highly specialized hospitals. A few hospitals are run has not given rise to the need for any special health by private societies and religious bodies, in some education programme. cases with public subsidies.Private initiative takes Vital statistics in Denmark are arranged as follows : a great part in the fight against disease; the National the Government Statistical Department collects and Association against Tuberculosis, for instance, has publishes the usual health and vital statistics, while played a major role in tuberculosis control, and similar a special section of the National Health Service associations are now in action against cancer, rheu- deals with medical statistics proper, such as diseases matic fever and poliomyelitis. and causes of death, medical personnel, hospitals, At the end of 1954 there were 5332 physicians, matters relating to hygiene, etc. of whom 4907 were in active practice in Denmark - The birth rate is practically stable, the latest figure one for every 898 of the population.At the same being 17.2 in 1956.The death rate in 1956 was 8.9, time there are 2300 dentists (of whom 1331 have and the infant mortality rate -which has been declin- independent practices) -that is, one for every 3310 in- ing steadily- reached the low figure of 24.9.In the habitants.The number of midwives was 728, or same year neonatal deaths were17.7 and foetal one for every 1817 women between the ages of 15 deaths after the 28th week were 17.7. and 49.There were 13 650 authorized nurses in The first modern health legislation in Denmark, active work.Over 10 000 of these were occupied which dates from 1888, applied directly only to the in hospitals and other curative institutions, 1250 in major diseases such as cholera, smallpox and plague, local government home nursing, 587 in infant and but its provisions have steadily been extended.In school health nursing, the remainder being engaged as 1943, a law providing for vaccination free of charge private nurses or at children's institutions, etc. against diphtheria forall persons under the age The following table shows the number of active of 18 years was introduced.Vaccination campaigns members in State -approved health insurance funds undertaken following this legislation have resulted EUROPEAN REGION 245
in the eradication of diphtheria from the country. The National Health Service is responsible for the Since 1950, combined diphtheria and tetanus vaccina- approval of dentists as practitioners, after examina- tion has been given.The only epidemic disease tion by the Danish High School of Dentistry and which has caused trouble in recent years is polio- two years' subsequent service with a qualified dentist. myelitis, but now every person has an opportunity At the end of the school year 1954 -55 free dental care to be vaccinated and it is hoped that epidemics will for children was given in the capital, in all towns be limited accordingly.All persons under 40 years and in approximately 37 per cent. of the rural districts. of age may be vaccinated free of charge and the Clinics have been established for free treatment of immunization is carried out by all physicians. children below school age whose parents' income is Tuberculosis patients are treated mainly in sanatoria below a certain level.For adults the sick clubs pay run by the National Association against Tubercu- for their members part of the cost of dental treatment. losis with subsidies from the State, or in communal Since 1945 the health of expectant mothers can tuberculosis hospitals, which are the centre of a be checked free of charge by a physician at three system for chest clinics covering the entire country. consultations and by the midwife at six consultations These hospitals and clinics are run by county and during pregnancy and one after the birth.Increasing town councils with State subsidies. BCG vaccina- numbers have taken advantage of this, and in 1954 -55, tion is offered free of charge to all negative reactors 95 per cent. of the mothers came for the first medical and it is carried out as a routine prophylactic measure consultation, although only 72 per cent. completed in childhood.In 1954, Denmark had 64 institutions all three visits.Fifty -eight per cent. used the oppor- with 4021 beds (0.9 per 1000 population).There tunity to see the midwives.Midwives who have are now chest clinics in every county, numbering 102 followed a three -year training course assist in home in all.In most areas the head of the clinic is a spe- confinements.Some 60 per cent. are employed by cially trained physician who is also in charge of the the public authorities in order to ensure a proper local tuberculosis hospital.The effective work of distribution throughout the country.In about two - control, which has been going on for many years, thirds of the deliveries at home a doctor is present. has resulted in such a considerable decrease in the About 45 per cent. of all children are born in hospitals incidence of tuberculosis that it has been possible to or other institutions.Where there are complications close a number of communal tuberculosis hospitals the birth takes place in hospital as a rule.The and some of the sanatoria.It is hoped that before health funds pay the cost of medical aid in general long tuberculosis may be considered to have been but hospital charges are paid by the insurance only eradicated from Denmark. if complications are expected. A government com- The treatment of diseases outside the hospitals is mittee in 1956 issued a report suggesting special in the hands of general practitioners and specialists. measures for closer co- operation between doctors, The right to practise medicine is open to all registered midwives,' clinics and hospitals and the establishment physicians, but special approval is required for the of new maternitydepartments.Therearealso title of specialist.As a rule the family doctor is maternity aid institutions established under an Act entitled to send his patient to the district hospital of 1939, amended in 1956, to provide advice and for x -ray or laboratory examination, but the major economic assistance to expectant mothers and mothers consultative laboratory work is carried out at the with young children.Today there are institutions in State Serum Institute in Copenhagen. all parts of the country, and the majority of un- General advances have been made in the care of married mothers and a growing number of married the sick in their own homes. A large number of mothers avail themselves of this service.The cost communes and private associations have arranged a of operating these centres is shared by central and system by which a qualified nurse may be called in. local governments with the co- operation of private An Act has recently been passed which makes the organizations.By an Act of 1946 every woman communes responsible for satisfactory arrangements who fulfils the conditions of admission to a sick of this kind.Practically all the towns and half of club (approximately 75 per cent. do so) may receive the rural communes employ home helps, who may daily and free of charge half a litre of whole milk be assigned by doctors where illness prevents the from the third month of pregnancy until six months housewife from attending to her ordinary work. after the birth of the child, for whom an additional Dispensaries have been established for the super- half -litre is provided. The expenses are defrayed by vision of children under seven years but most of the Government and the commune.For infants these duties are normally undertaken by public health under one year the parents can obtain supervision nurses visiting the homes. by public health nurses, who pay between 12 and 246 FIRST REPORT ON THE WORLD HEALTH SITUATION
19 visits to the home during this period.Up to the financial means.There are two subsidized private present time this service covers only about 60 per cent. institutions.About 16 000 persons are subject to of the new -born, chiefly owing to a shortage of fully public care as mental defectives, of whom about trained public health nurses.Supervision can be half are maintained in institutions and the rest are supplemented by medical examination of the child boarded out in private families or supervised outside at three consultations.This is generally done by the the institutions.There are also special residential family doctor and can be continued until the child and day schools as well as employment homes for reaches school age.The doctors and midwives are thementally backward.Thegreatmajorityof paid by the State, which also shares with the communes hospitals for mental diseases are State concerns. expenditure on the salaries public health nurses.Free They represent a separate section of the health medical consultations are provided for healthy pre- system and come under the directorate of the State school children, and about 50 per cent. take advantage mental disease hospitals.At the end of 1954, there of this service. was a total of 11 287 beds divided as follows: seven Allschools,public and private, must appoint State hospitals with 7458 beds; two municipal hospitals school doctors (normally one for every 1500 -2000 child- with 2785 beds; one private hospital with 212 beds; ren) and annual medical examinations are obligatory. five psychiatric departments in general hospitals with One school nurse may be appointed for each doctor, 538 beds; beds in other general hospitals -20; one and many schools have appointed school dentists as municipal sanatorium for nervouspatients, with well.The school doctors are called in at intervals 117 beds; and two private clinics for nervous patients, to give short courses of instruction on child hygiene with 29 beds.Mental hospitals in Denmark, as in and the diseases of children. so many other countries, are due for extensive modern- A revised law of 1954 provides, under the Ministry ization and reorganization. of Social Affairs, an all-round factory inspectorate The main sanitary laws date back to the middle with a special corps of physicians.The work includes of the 19th century.At present, sanitary regulations the inspection of hygienic conditions and the investiga- are in operation in all provincial towns and in almost tionof occupationaldiseases;thetreatmentof all the rural districts.The regulations set out rules patients who have contracted occupational diseases is for water supply, drainage, and all the usual environ- given in the general hospitals. mental requirements.Certain towns, especially Co- Ten municipal nursing homes with a total of penhagen, have houses and areas which are unfit for 570 beds have been established for the care of the habitation according to modern standards, but it is chronic sick.If there are no public beds available generally recognized that slums as known in many the local authorities can admit patients to private countries do not exist in Denmark.Great attention nursing homes and pay the costs.As a general rule, is paid, especially in the cities, to the provision of old -age pensioners are members of a State -approved light and air for dwellings and to the lay -out of both health insurance fund and are thus entitled to its private houses and factories or business premises. benefits.In exceptional cases the local authority will The Town Planning Act of 1938, which applies to grant special assistance to old -age pensioners without the whole country, makes itpossible to separate any obligation for repayment.Under the National industrial from residential areas to a greater extent Pension Scheme, old -age pensioners maintained in than was formerly the case.It also contains powers homes for the aged receive regular medical attention. to ensure the planning and siting of new houses. The average calorie intake in Denmark is about The State Serum Instituteis Denmark's central 3300 a day.Since the war the trend in the choice laboratory for bacteriological and serological tests, of food from the point of view of nutrition has been and it also produces sera and vaccines for use at unfavourable.The consumption of fruit, milk and home and abroad.Scientificresearchin many vegetables is decreasing and that of sugar is on the fields is carried out in the Institute.Serological tests increase.Regular surveys are made to maintain the for syphilis are made as a matter of routine for all nutritional balance of the population and special persons admitted to Denmark's hospitals.In the surveys have extended to Greenland.Definite work State Vitamin Laboratory, instituted in 1931, scientific on nutritional education is carried out in Denmark studies are made on vitamin preparations, as well for both children and adults. astestsforsafer foodstuffs,nutrition, drinking - The care of mental defectives in Denmark is the water, etc.It is becoming more and more usual responsibility of the State.Where the patient, or the for the central laboratories to carry out tests for person who is liable to maintain him, is able to pay, general practitioners, and this development is favoured a charge is made for institutional care according to by the local authorities. EUROPEAN REGION 247
FINLAND
Finland lies on the Baltic Sea between the Gulf of Finland on Medical Board was established in 1801 and officially the south and the Gulf of Bothnia on the west.Its land boundaries are with the Union of Soviet Socialist Republics, recognized in 1816. Sweden and Norway. The area is 337 009 square kilometres, Lectures on medical subjects were given at the Uni- including the numerous inland waters.Of this area about versity of Turku, established in 1640, but the first full 70 per cent. is forest, 9 per cent. is lakes, 9 per cent. is cultivated development came about a hundred years later, and and 12 per cent. is unsuitable for cultivation.The climate is it was not until the 19th century that a system of cold continental with severe winters. At the 1950 census the population was a little over 4 million, district doctors was organized.At that time the and the annual rate of increase is stated to be 0.65 per cent. more important towns had their own doctors.In the (4 315 100 in 1956).Approximately 3 700 000 speak Finnish; second half of the 19th century, the first doctors for 350 000 are Swedish -speaking and 11 000 have other languages. rural communities were appointed, and since 1885 About 65 per cent. of the population are rural.The capital, Helsinki, has 426 133 inhabitants (1956). these communities have received financial support For local administration, the country is divided into ten from government funds for the employment of phy- provinces, each headed by a Governor appointed by the Pre- sicians.This service has gradually extended along the sident.The unit of local government is the commune and each same lines, and at present each commune, rural or rural parish and each town forms a commune. There are urban, employs one to three communal public health 35 towns, 30 boroughs and 483 rural communes. The economy is agricultural and industrial.The chief crops officers.In 1943, the former district doctors were are potatoes, wheat, oats, barley and rye.Dairy products are replaced by provincial public health officers. also considerable.One of the main industries is forestry and The history of modern hospitals in Finland begins sawn lumber; paper and board are exported. in 1759, when the first public hospital in Turku was Since the Second World War, the national economy of Finland established. has shown a continuous upward trend.The real per capita By the end of the 18th century there income has increased nearly 3.8 per cent. yearly, thus greatly were six provincial hospitals in the country, with improving the general standard of living.There has also been about 60 beds.In 1828 the University moved from an intensive activity in social legislation, and although the Turku to Helsinki, and in 1833 the first university problem of sickness insurance has not yet been solved, there is clinic was established to provide more beds and to a sense of increased security which certainly reflects on the people's health. as a training institute for medical students. The school age in primary schools is from 7 to 15 years. Progress was fairly slow, but several town hospitals Finland has a considerable mercantile marine, and the lakes, were established later in the 19th century, and rural connected by canals, provide a remarkable system of inland communities also started their own hospital pro- communication, with a navigable length of about 4300 kilo- grammes. metres.There are about 35 000 kilometres of high roads Today, by far the most important part and 29 000 of other public roads.Railways, which are State - of the hospital service is in the hands of municipal owned, extend to over 5000 kilometres. and rural communities and the community associa- Since 1945 the Ministry of Social Affairs has contained tions. six departments, dealing with such matters as research, housing, The main principles underlying the health service labour, insurance and welfare.The social insurance system provides family allowances, maternity allowances, vocational in Finland are: (1) Local initiative: to a large extent training and rehabilitation.In 1953, 139 000 were covered for the local population organize their health services sickness and maternity benefits and 2.25 million for old -age, within the frame of local autonomy.The main invalidity and survivors' pensions. function of centrallegislationistoco- ordinate. (2) Government control: the Government, through its Health medical agencies, sees to it that the local authorities fulfil their health obligations.It is specially concerned There was no centrally controlled organization of with co- ordination and takes responsibility for special medical services in Finland before the 17th century. activities which cannot be properly decentralized. An association called the Collegium Medicorum was (3) Financial support: the Government generally covers established in 1673 under private initiative, to create 50 per cent. or more of the health service costs of some order in health services.Twenty -five years local authorities.It also supports to some extent later, this body was officially accepted by the Govern- voluntary public health activities. ment, as the King in 1688 approved the Constitution For administrative purposes, Finland is divided of the Collegium and gave it authority to control all into nine provinces, and one autonomous province. the medical services in the country.The separation To effect the governmental control of local health of Finland from Sweden, and union with Russia in services there is a province doctor in each, appointed 1809 did not interrupt this development, since a State by the Government. He performs educational and 248 FIRST REPORT ON THE WORLD HEALTH SITUATION advisory functions in the communities, and at the same diseases, cancer and tuberculosisisstill a major time maintains contact with the provincial adminis- problem- especially as far as the rehabilitation and tration of the State Medical Board.The highest pro- resettlement of patients recovered from tuberculosis fessional authority is the State Medical Board, which are concerned. acts under the Minister of the Interior and is respon- (2) Both the absolute and the relative role of acci- sible for health problems of nation -wide importance. dents is becoming increasingly serious; new problems These responsibilities can be set out as follows: are created -especially in rehabilitation and after- (1) to supervise, develop and control the health care. services; (3) Sparse population and poor communications (2) to operate health services whenever decentra- cause great difficulties in the transport of the sick. lization is out of the question, as central laboratories, (4) The number of hospital beds, particularly in medico -legal work, training of health personnel other mental hospitals, is still insufficient to meet the needs than doctors and professional auxiliaries, collecting of the increasing population. health statistics on a national basis and developing international collaboration in the health services. (5) The trained health personnel are too few for the operation of an effective system.It seems pro- The health services can be divided, for the purposes bable that the number of doctors and dentists would of description, into three branches -prevention, care be far too small for several decades to come; of the sick, and rehabilitation and care of the chronic (6) Health services for the population of working sick. age and for the aged are not developed to the same On the preventive side, local authorities are respons- extent as services for children.Preventive services ible for maternal and child welfare, school health, the among those groups are mainly operated by voluntary control of infectious diseases (including tuberculosis), organizations.No general sickness insurance system health,environmental health,hygieneof mental exists as yet in Finland, although plans are in prepara- foodstuffs, and the control of occupational safety tion. and hygiene.For administration there is a public health board in each community which has to employ For general hospital administration there are 21 the necessary personnel, such as the community central hospital districts, of which six already have doctor, the nurse, the midwife and the health inspector. their central hospital.Where central hospitals do Doctors are appointed by the State Medical Board not exist, State -owned provincial and general hospitals and the other personnel by the local authorities. provide general hospitalcare.In some districts Communities are responsible for the care of the where distances are great, associations of communities sick, and legislation requires them to cover the costs have regional hospitals.New central hospitals are of a sufficient number of beds in general and mental being built, and it is expected that all the 21 central hospitals and in sanatoria.At the present time, some hospitals will be completed by about 1970.In 1956, part of the large general hospitals is still a govern- hospital beds were distributed as follows : ment responsibility, but the trend is towards complete General hospitals 13 148 control by the local authority. Mental hospitals 11 496 Chronic sickness often results in reduced income and Epilepsy sanatoria 212 impaired economic conditions.As the local Welfare Maternity hospitals 1 946 Administration is responsible for the economically Tuberculosis sanatoria 6 399 handicapped, the care of the chronic sick and of Venereal diseases hospitals 227 Infectious diseases hospitals 1 158 mentally or physically handicapped personsfalls within the range of their services. Total 34 586 The great distances to be travelled, the unfavour- able climate, the sparse population, together with the For the care of tuberculosis patients, the country increasing rate of industrialization and urban develop- is divided into 19 districts, each of which has a central ment, dictate the obvious health problems of modern tuberculosis sanatorium. Inaddition,thereare Finland.To some extent the after -effects of war can tuberculosis dispensaries in the districts, responsible still be felt, especially in housing conditions. for registration and, if possible, hospital care of new In the matter of personal health, the following tuberculosiscases.In 1956,there were 48 such points are of importance : dispensaries. (1) Although the mortality rate has been favourable In most health services, the municipal and communal in recent years, the prevalence of cardiovascular health administration can be regarded as the health EUROPEAN REGION 249 unit, where preventive health service and the care of There are about six doctors to every 10 000 inhabi- the sick are a single functional organ.This is the tants. basic combined service. The State Medical Board employs a small statis- There are two medical faculties in Finland, at the tical unit which covers the statistics of the health Universities of Helsinki and Turku.After a mini- services.It also maintains a national tuberculosis mum of five terms, the medical candidate examina- register.Statisticsonmortalityandcausesof tion is taken and the candidate then serves for seven death are, however, compiled by the Central Statis- terms in different clinics and takes examinations in tical Office, as are the general vital statistics. 14 different subjects in order to obtain the licentiate The birth, death and infant mortality rates for the of medicine.For specialist'stitle and rights the period under review were as follows: doctor generally has to serve four years in some 1954 1955 1956 university clinic or in another large hospital; this Birth rate 21.5 21.2 20.7 training is entirely controlled by the Finnish Medical Death rate 9.1 9.3 9.0 Infant mortality rate 30.6 29.7 25.7 Association, which also arranges annual post -graduate courses of two week's duration for doctors, especially Medical care in the homes of the people is provided communal public health officers.Training for dentists mainly by the community doctors.Care of the sick is provided at the University of Helsinki.For the is the major part of their work, but opportunities for training of nurses there are 21 nurses' schools in preventiveworkareincreasing.Privatepracti- Finland, of which 15 are State owned, six being muni- tioners live mainly in the larger centres, and conse- cipal or private institutions; the training period is quently the community doctors have to provide most two and a half years with additional specialization of the medical care in rural areas.Nurses, midwives of one year.Nursing education is controlled by the and assistant nurses play an important part in nursing State Medical Board.Midwives are trained at a care in the home. State -owned midwifery school withamaternity In 1956 there were 1623 dentists in Finland, i.e., hospital in Helsinki. one dentist for every 2700 inhabitants. There are numerous voluntary organizations assis- The maternal and child health systems in Finland ting in the health service at different levels.Their are identicalin administration and organization, main function is to carry out health education but and they will therefore be described together.Accor- they often support research in the field as well, es- ding to law, the communities have to establish one pecially in the fight against diseases like tuberculosis, or more maternal and child welfare centres, taking cancer, and rheumatism.Practically all these organi- intoconsiderationthepracticalpossibilitiesfor zation senjoy State support, but the State authorities mothers and children living at a distance to reach a do not interfere with their internal affairs.Co- opera- centre.In 1956 there were 783 MCH centres with tion between voluntary and State authorities has always 2111 sub -centres, and 812 child welfare centres with been good. 2953sub -centres.Thoughvisitstocentresare There is no regular health education system; this entirely voluntary, only six per cent. of mothers and is provided in connexion with the practical work of seven per cent. of children are outside the services. the staff and is mainly based on individual contacts. Though the communities alone are responsible for Some health education is included in the school the organization of maternal and child health services, curriculum and variouspubliceffortsare made they are subsidized by the Government; the State through the press and radio. Medical Board, however, supervises their activities. At the end of 1956, the health personnel in Finland The health service in primary schools has been esta- was as follows: blished by legislation.The communities employ part - Total Active time doctors, usually the community doctor, for the registered schools.The service is subsidized by the Govern- Doctors 2501 ment, and the State Medical Board as the highest Dentists 1623 authority supervises activities. Veterinarians 318 Nurses 12205 7951 There is extensive legislation in Finland for the Midwives 4328 1707 protection of employees.The protective measures Laboratory technicians . 129 93 cover, for example, the length of the working day, X -ray technicians 114 86 factory inspection (thereis,however, no medical Medical gymnasts 283 77 factory inspection), industrial accidents, and occupa- Practical nurses 3224 1910 Psychiatric nurses 5117 2336 tional diseases.For injuries and diseases due to Children's nurses 2061 886 occupational environment, the employee is entitled 250 FIRST REPORT ON THE WORLD HEALTH SITUATION to compensation according to detailed rules defined For sero -bacteriologicalservicesthe countryis in the laws.Numerous relief funds are in operation, divided into six Laboratory Districts, each of which securing compensation for sickness and other hazards hasaState -supported sero -bacteriological control for some 250 000 industrial workers.For scientific laboratory, with a pathologist and a chemist on the research in the field of occupational health there is staff.Some of them also have university and commu- the Institute of Occupational Health at Helsinki, nallaboratories.TheStateSerumInstitutein operating partly on government subsidy. Helsinki isthe most complete central laboratory, Health care for the chronic sick and for the aged which functions at the same time as a salmonella, in Finland belongs mainly to the sphere of the Ministry shigella and influenza centre.This institute com- of Social Affairs, and isstill in an early stage of prises complete serological, bacteriological, virological development.The chronic sick and the aged benefit and anaerobic departments, as well as blood grouping, from local health services, such as the visits of the hormone, and chemical departments.The work of nurses, but they receive their most important aid from other Statelaboratoriesislimited principally to the Communal Welfare Boards.The communities serological andbacteriologicalinvestigations.In are obliged to finance, separately or in association Statelaboratories,verificationof communicable with neighbouring communities, homes for the aged, diseases, venereal diseases, and of tuberculosis, and where a sufficient number of beds for the sick must be determination of blood groups for maternity welfare maintained.The role of voluntary and religious centres are free of charge.In addition, the sero- organizations in the care of the chronic sick and the bacteriological investigations for the State hospitals aged is considerable. are provided free of charge. The most notable trend in nutrition is the increasing Histopathological specimens are examined by the use of milk and dairy products in Finland.The university laboratories and a few private pathologists Government, using various measures, supports this at fixed fees.Clinico- chemical tests are conducted in development, and also pursues an agricultural policy hospital laboratories, some of which also provide in order to render the country self -supporting in the these services for persons outside the hospital.Private production of cereals as well. practitioners have to resort to private laboratories The country is divided into 18 districts for the for their tests, there being a network of such labora- mental health service, each district being obliged to tories all over the country. run a central mental hospital with a sufficient num- According to legislation dating from 1927, local ber of beds.There are about 10 700 beds in these authorities are responsible for environmental health hospitals, and about 500 beds in State -owned mental services, though they are supervised by provincial hospitals.For preventive activities,after -care and authorities and several ministries. resettlement of patients there are so far only seven psy- About 80 per cent. of the urban population in chiatric centres in operation, but new centres are being Finland is supplied with piped water, most of the built.For the care of chronically sick mental patients, waterworks operating complete chemical purification recent legislation has drawn up a building programme systems.On the other hand, only about 8 per cent. forso -calledB- hospitals,theneed of whichis of the rural population has the advantage of a public estimated to be about two beds per 1000 inhabitants. water supply.The situation in respect of sewage Primarily, both the prevention and the care of disposal is essentially the same, but an increasing communicable diseases are the duty of local Health number of rural households have access to sewers, Boards.Each verified or suspected case must imme- though they may have no piping. diately be reported to the Board, which, in turn, has Industries are the most important factor in water to investigate without delay the nature of the disease, pollution, in particular the paper and pulp industry its spreading, cause and source.The Board has to with itsvast quantities of waste.Purification of give such instructions and take such precautions as public sewage is also a problem, as septic tanks are are considered necessary under the circumstances and practically the only means of purification.There are may apply to the provincial health officer and the complete biological purification plants only in the ten State Medical Board for assistance.The latter has biggest towns, and these plants are of insufficient an epidemiological department with an epidemiologist capacity.Microbic pollution of water is, therefore, and a specially trained nurse.The cost of prevention a difficulty in Finland, though natural purification in and care of communicable disease is borne mainly the large lakes and rivers is rapid, thus rendering the by the communities. problem less acute. EUROPEAN REGION 251
FRANCE
France is in western Europe, with coastlines on the Channel by the fact that the State alone issues certificates and diplomas. and the Atlantic Ocean to the north and west, and on the Medi- At the present time 6.5 million pupils and students are attending terranean to the south.Its neighbours to the north are Belgium the State schools, colleges and faculties, and 1.5 million are and Luxembourg, to the east Germany, Switzerland and Italy; attending private educational establishments. to the south -west the Pyrenees separate it from Spain.Its Politically, France is a republic, based on the existence of climate is temperate: maritime in the west, semi -continental in three separate authoritative bodies -executive, legislative, and the east, and Mediterranean in the south. judicial -the President of the Republic being the supreme arbi- The country covers an area of 551 000 square kilometres. trator.The President of the Council of Ministers, who is head At the last census, in 1954, its population was 42 777 174, of of the Government, holds the executive power; the legislative whom 1 500 000 were residents of foreign origin.Atthe power is in the hands of the parliamentary Assemblies, elected beginning of 1958, the population was estimated at 44 289 000. by universal suffrage. The average density is 78 per square kilometre. Administratively, France is divided into departments; there The economy of France is both agricultural and industrial, are 90 metropolitan departments as well as those of Algeria, the latter having developed very considerably since the last war. Martinique, Guadeloupe, French Guiana and Réunion. 1In It is estimated that 7.5 million persons are engaged in agriculture, each department the Government is represented by a prefect, who 4.5 million in industry, and 1.5 million in commerce.The urban exercises authority over all the departmental services attached population represents about 56 per cent. of the whole; there are to the various ministerial administrations. An elected Assembly, 24 towns with more than 100 000 inhabitants, and Paris, the the Conseil général, is responsible for the management of depart- capital, has a population of 2 850 000. mental affairs, and it is this body which votes the departmental There are 186 000 square kilometres of cultivated land, budget; its decisions are subject to the approval of the central 123 000 square kilometres of pasturage, 15 750 square kilometres authorities.The departments are divided into districts (arron- of vineyards, 113 000 square kilometres of woodland, and about dissements), each with a sub -prefect; districts are in turn sub- 56 000 square kilometres of moors and uncultivated land. divided into cantons, and cantons into communes.There are The main agricultural products are wheat, barley, rye, maize, about 40 000 communes, these being the smallest administrative oats, potatoes and sugar -beet.Orchards abound and are units; communal affairs are managed by an elected Assembly - very productive, and vineyards are cultivated on a very large the municipal council -and are administered by a mayor elected scale.Livestock -raising, milk and dairy produce also constitute by the municipal council. important items in French agriculture. France produces coal, copper, lead, silver, antimony, salt, etc., and petroleum production has recently begun to be developed. Health The principal industries include metallurgy, chemicals, textiles, glass and pottery, jewellery and cabinet -making.The chief The Ministry of Public Health and Population is imports are crude petroleum, coke, machinery, untreated hides, the supreme authority in health matters at the national rubber, copper and coffee.Exports include chemical products, level.Although certain healthservices(suchas textiles, motor vehicles, glassware, perfumes, soap, and wine. There are about 82 000 kilometres of national highways, industrial health and school and university health 267 000 kilometres of departmental or main (inter -communal) services) are attached to other administrations, the roads, and nearly 300 000 kilometres of local roads.There are Minister for Public Health and Population retains about 42 000 kilometres of railways, of which more than 4000 ki- responsibility for health conditions in the country lometres are electrified.The national airline runs services as a whole, and ensures technical supervision and extending over 310 000 kilometres.Rivers and canals provide 9000 kilometres of navigable waterways. co- ordination of all activities connected therewith. Owing to the geographical characteristics, climate, and cultural At the central level, the Ministry of Public Health heritage of France, the tourist trade has been highly developed and Populationcomprisesfourdepartmentsor and is today one of the primary factors in the country's economy. services: general administration; public health admi- By far the greater part of French economy is in private hands. nistration; the central pharmacy service, and general Nevertheless, this does not by any means apply to the national welfare. economy as a whole, and many industries are nationalized, administrationofpopulationand The including coal, gas, electricity, atomic energy, a large part of responsibility for administration of healthaffairs insurance, and the largest company producing automobiles. rests with the Department of Public Health Administra- There are also undertakings run on a mixed -economy basis, in tion and - in its more limited sphere - with the which private capital is invested but in which the State is often Central Pharmacy Service. the most powerful share-holder--such as petroleum, railways, shipping companies and airlines, aeronautical construction, arms The Department of Public Health Administration manufacture, etc.Present -day French economy is essentially has four main divisions which are responsible res- one of " controlled liberalism ". pectively for: (a) the practice of medicine and allied Since the French Revolution, education in France has been professions; (b) problems of hospital organization, " free and the same for all citizens ".Nowadays, school attend- building, and maintenance; (c) public hygiene (control ance is compulsory from 6 to 14 years of age.There are three grades of schooling: primary, secondary and higher.Technical education is also available.Schools may be public (i.e., belong- 1 See page 255 (Algeria); pages 182 -183 (Martinique, Guade- ing to the State) or private; uniformity of teaching is maintained loupe and French Guiana); and page 132 (Réunion). 252 FIRST REPORT ON THE WORLD HEALTH SITUATION of communicable diseases, sanitary control of frontiers, Although strictly speaking there are no health environmental sanitation, thermal spas, and public administration services at the regional level, certain health laboratories); (d) social hygiene (health protec- functions of a regional nature are carried out (in tion of mothers and children; control of tuberculosis, addition to their departmental duties) by some high- leprosy, cancer, rheumatism, diabetes, venereal dis- grade Directors of Health - or Divisional Inspectors eases, mental diseases and alcoholism; organization - residing in large towns in which there are faculties of blood transfusion services; health problems relating or schools of medicine and large hospital establish- to old age and the aging of the population; functioning ments.One example of such regional functions is of the medical social welfare services).Furthermore, the planning and putting into operation of the health an Office for International Relations ensures liaison equipment programme.In the same way, pharmacy withinternationalbodies concerned withhealth inspectorssupervise the application of laws and matters, and particularly with WHO. Within the regulations relating to pharmacy under the authority Ministry of Public Health and Population are con- of the Divisional Medical Inspectors and in liaison sultative committees which advise the Administration with the departmental Directors of Health.There on technical questions; among these are the French are 16 regional areas, each comprising a number of Higher Public Health Council (Conseil supérieur departments, and corresponding to the Social Security d'Hygiène publique de France), the Permanent Social areas - an arrangement which is essential for effective HygieneCouncil(Conseilpermanentd'Hygiène co- ordination of the two administrations. sociale), and the Higher Council for Hospitals (Con- In the towns, the mayor is responsible for ensuring seil supérieur des Hôpitaux). public health protection, under the administrative At the local level, health organization follows the authority of the prefect, and subject to the technical administrative pattern outlined above;itis based supervision of the departmental Director of Health. on the department, and the prefect of the department It is compulsory for a Health Office to be established is responsible for health administration.Under his in all towns with more than 20 000 inhabitants and in authority, it is the departmental Director of Health all communes with not less than 2000 inhabitants in who directs, supervises and co- ordinates the health which there is a thermal spa or a health resort.This services as a whole.This official, who is a physician, office is directed by a physician, working on a full - is a member of the Health Inspectorate staff, a body time or part -time basis according to the size of the of State officials attached to the Ministry of Public area and population, and technically responsible to Health and Population.The qualifications required the departmental Director of Health. in order to become a member of the Health Inspec- There are about 40 000 physicians in France, or an torate staff are as follows: (a) to have followed a post- average of one physician for every 1100 inhabitants, graduate university course leading to the Certificate although the ratio varies in different areas from one of Special Studies in Hygiene, Health and Social to 500 to one to 2000.Of the total number of phy- Work (Certificatd'étudesspécialesd'hygièneet sicians, some 11 000 are specialists in one or another d'action sanitaire et sociale); (b) to have passed com- of the branches of medicine or surgery.There are petitive recruitment tests organized by the Ministry about 15 000 pharmacists, 15 000 dental surgeons, of Public Health and Population; and (c) to have and some10 000midwives.Thetotalnumber completed a year's practical course at the National of nurses is 80 000, or a ratio of 1:550, but here School of Public Health and obtained the Public againtheproportionvariesfrom oneareato Health Diploma. another. The Director of Health acts at the departmental Medicine is a liberal profession in France; it is level for the central administration; his extremely governed by a legally constituted organization, the wide functions correspond to those described above National Medical Association (l'Ordre national des in connexion with the Department of Public Health Médecins), and only those persons who are registered Administration, and he is assisted by one or more with the Association may practise medicine.The deputies of lower grade but with the same qualifica- Associationhasdepartmentalcouncils,regional tions.The national consultative committees men- councils (disciplinary bodies), and a national council tioned above have their counterparts at the depart- composed entirely of practitioners elected by their mental level in such bodies as the Departmental fellow- members.The Association acts as intermediary Health Council (Conseil départemental d'Hygiène) between the medical profession and the public authori- and others which assist the prefect and for which ties at both national and departmental levels.Similar administrative services are provided by the Director regulations govern the practice of the para- medical of Health. professions, although there is no professional asso- EUROPEAN REGION 253 ciation for nurses, who are directly responsible to four -year equipment plan came into operation in 1954, the Ministry of Public Health and Population. to be followed by a second plan in 1958.The equip- Apart from the free practice of the medical and ment plan is based on the following guiding lines : para- medical professions, a certain number of phy- (a) reconstruction of hospital establishments which sicians, pharmacists, nurses and others are attached had been damaged or destroyed, modernization of to national public services (such as the Health Ins- old hospitals, and building of a certain number of pectorate and the Pharmacy Inspectorate), to depart- large hospital units; (b) awareness of the problems of mental public services(physicians attached on a mental disease; (e) increase in the already considerable full -time basis to the departmental social hygiene facilities for protection of maternal and child health; services), or to communal public services (medical (d) concentration and improvement of facilities for officers in charge of municipal health offices), or hold cancer treatment; (e) complete organization of blood salaried posts.The school and university health transfusion facilities; and (f) a new and large -scale services and the industrial health services also employ effort to provide further facilities for care of the aged. a large number of medical and auxiliary personnel. This plan has ensured that the programmes are har- Health establishments provide some 428 000 beds monized and co- ordinated at the national level, and in hospitals and hospices.Of this number, 346 000 has provided for State financial aid, which greatly beds are in government hospitals (198 000) and hos- encourages local communities.Furthermore, apart pices (148 000), and 82 000 are in private establish- from its equipment aspect, much emphasis has been ments.It may be noted here that it has always placed on matters which cannot be expressed in been a tradition in France for old people's hospices figures, such as the reception of patients, home care, to be an integral part of the hospital system.Hos- and the human element in medical care. pitals are classified, according to the size of the area An outline of health organization in France would they serve,in three categories with a greater or be incomplete without mention of the social security smaller number of services and degree of specializa- system, whose influence on the health and social tion.The smallest units are simply known as hos- development of the country has been, and stillis, pitals, larger establishments are called hospital centres, very great.The most important feature of this and the largest (which are set up in towns with a system is that it covers, without distinction, all men faculty or school of medicine) are regional hospital and women who work for their living, as well as the centres, providing facilities for treatment, teaching dependent members of theirfamilies.Insurance and research.For administrative purposes the small- covers first of all sickness risks; the insured person est unit, the hospital, is based on the commune and isentitled to reimbursement (up to 80 per cent., is managed by an Administrative Committee under and in some cases up to 100 per cent.) of fees for thechairmanship of the mayor.Itnevertheless medical consultation,in- patient careinhospital, forms part of the departmental and regional health dental care, laboratory examinations, and purchase facilities, and it is at the regional level of the Divisional of medicaments and orthopaedicappliances.In Inspector that all hospital equipment programmes case of long -term illness (such as tuberculosis), the are drawn up and competitive recruitment of medical insurance covers all expenses without any time -limit; staff for the hospitals takes place. for the patient, it also includes the payment of an There are, furthermore, the following facilities for allowance equivalent to one -half of his salary for the control of diseases of social importance: 71 700 a maximum period of three years.Secondly, insur- beds in tuberculosis sanatoria and preventoria, with ance covers maternity benefits, which are of a similar an additional 4000 beds for rehabilitation; 16 regional nature, and, finally,it covers invalidity and death. cancer control centres (with a total of some 2000 beds) French demographic policy has led to the inclusion where case -finding, treatment, research and training in the social security system of important provisions are carried out; 471 mental health clinics and 100 for the assistance of families, such as maternity psychiatric hospitals, with a total of 100 000 beds. benefits, pre -natal allowances, single -wage allowances, Other specialized units include 110 blood transfusion family allowances and housing allowances; italso centres and stations, and a very large number of provides for assistance to aged persons, such as establishments providing maternal and child health old -age pensions and allowances to aged remunerated services, including 9000 infant welfare clinics. workers.It is generally believed that family allow- The problem of medical care was of first importance ances have had a considerable influence on demo- after the war, on account of the losses and damage graphic evolution.Certain supplementary guaran- sustained by the hospitals, and very considerable tees are provided with respect to accidents of employ- efforts were made from 1946 onwards; thefirst ment andoccupationaldiseases.Allphysicians 254 FIRST REPORT ON THE WORLD HEALTH SITUATION without distinction may attend socially insured persons, bidity has not diminished in the same proportion, and the latter are free to choose their own physician. and this fact must be borne in mind since it indicates In this way the advantages of social security have the directionin which furtherefforts should be been reconciled with the free practice of the medical made. profession. With regard to venereal diseases, less than 1000 The social security system is not limited to insurance cases of syphilis were recorded in 1956, as against against risks or expenses; the social security bodies more than 15 000 in 1946. also take an active part in preventive work and pro- With the exception of smallpox, of which a few motion of health from many points of view, and they foci have appeared intermittently (caused by imported are thus closely associated with the national health cases which have been rapidly controlled), the great administration.In particular they provide financial epidemic diseases have practically disappeared. assistance, in addition to that of the State, for the In the ten years preceding the war, the annual constructionorrenovationof establishmentsfor notifications of diphtheria averaged about 20 000. medical and preventive care; they also devote large There was a marked rise in prevalence during the sums to such subjectsas research, teaching, and war, nearly 48 000 cases being notified in 1943, but health education. from 1946 onwards it began to decline and has been During the past ten years there has been a decline falling at an increasing pace during the past ten years; in the general death rate and a rise in the birth rate. in 1957 only just over 1000 cases were notified.On the The death rate, which was 19.5 in 1944, has fallen other hand poliomyelitis morbidity has increased; to 12.0 since 1954; the birth rate fell from 14.6 in 1939 until 1939 not more than 500 cases were notified each to 13.1 in 1941, but rose to 21.0 in 1947 and has year, but since 1945 the average annual notifications remained high since then.The population of France have been of the order of 1000, 1500 and 2000.The has therefore been increasing regularly for the past most serious outbreak was in 1957, when 4073 cases ten years, and furthermore the population is on were notified. the whole younger in spite of the longer average The disappearance or regression of certain com- expectation of life.This increase in life expectancy municable diseases has been due, if not exclusively, raises delicate economic, social and health problems at least to a very large extent, to the general application in connexion with old people, but these problems of preventivevaccination, and particularly those will be easier to solve in view of the increased birth which have been made compulsory in France (against rate and the larger place in the age -pyramid which smallpox, diphtheria, tetanus and tuberculosis).Im- will be taken up by the active and productive elements provement of living conditions hasalso had an of the population in the years to come. When the effect. birth rate was at its lowest, infant mortality reached At the same time new problems have arisen to claim its highest level, rising from 61 in 1939 to 108 in 1945. the attention of the health authorities, such as the It then declined gradually until in 1957 it was 29. growing number of mental patients, the progressive In some areas even better rates have been recorded increase in cancer morbidity, the extension of rheu- - 24, and even 19.These figures make it incumbent matic and cardiovascular diseases and others.More- upon the public authorities to increase their efforts over, the focal points have changed in many of the to obtain a further reduction of infant mortality in fields which have already been largely explored; France in the future. in environmental sanitation, for example, the tradi- Morbidity and mortality from communicable dis- tional sanitation problems of drinking -water supplies eases rose considerably as a result of the war, but and sewage disposal are nowadays of greater concern here again the situation has completely changed in in rural than in urban areas, whereas the populated the past ten years.In 1936, mortality from tuber- industrialareasfindthemselves confronted with culosis was 118 per 100 000 population; in 1942 it new issues, such as air pollution and the necessity had reached 158, but by 1956 it had fallen to 28.5. for controlling noise.In child health care,also, The decline has been rapid and continuous since emphasis isbeing placed at the present time on 1946, at an average rate of about 8 per cent. a year. investigation of peri -natal mortality, the care of pre- This development has been all the more remarkable mature infants, and on study of the part played by in that tuberculosis mortality has decreased much accidents in general infant mortality. more rapidly than general mortality; in 1943 it re- On the whole, it may be said that the health situation presented 9 per cent. of all deaths, while ten years in France has improved considerably in the past later - in 1953 - only 3 per cent. of all deaths were ten years as a result of better living conditions and due to this disease.Nevertheless, tuberculosis mor- economic and social progress. EUROPEAN REGION 255
* ** and this has also had a very beneficial effect upon the health services. Algeriaisa constitutional part of the French Health services in Algeria are similar to those in Republic.Itissituated in North Africa between the other departments of metropolitan France, with Tunisia and Morocco, and extends for 1000 kilo- certainadaptations required for theorganization metres along the shores of the Mediterranean opposite of medical care and preventive services for scattered the sea coast of Languedoc and Provence.Its total rural populations. area is 2 205 000 square kilometres. Facilities for medical care in Algeria in 1953 included For administrative purposes, Algeria isdivided 135 hospital establishments (of which 112 were general into a group of departments, each under the authority and 14 were specialized hospitals) with a total of of a prefect.The population of the Algerian depart- 24 284 beds.Since that time emphasis has been laid ments is 10 028 000. primarily on the construction of establishments for The economy of Algeria still rests mainly on the the treatment of tuberculosis patients and mental products of the soil, cereals being grown on more cases. than half the arable land.The subsoil is particularly It should be noted that there are certain endemic rich in iron, phosphate and petroleum.For the diseases in these departments which are not found past few years a great effort has been made to mod- in the other departments of metropolitan France, the ernize production methods and processing industries, most important being malaria and trachoma.
FEDERAL REPUBLIC OF GERMANY
The Federal Republic of Germany is bounded on the east Health by the German Democratic Republic and by Czechoslovakia; on the south by Austria and Switzerland; on the west by France, In 1919 a State Constitution came intoforce Luxembourg, Belgium and the Netherlands; and on the north which gavetheCentral Government concurrent by Denmark and the North Sea, on which open the ports of powers with the Lander on certain important matters, Bremen and Hamburg. The northern plains rise gradually includinghealth,veterinarymedicine,population to culminate in the Bavarian Alps on the Austrian border. The area, including the Saar, is 247 946 kilometres. policy, maternal and child health and the health care The Federal Republic covers ten states, or Lander, comprising of adolescents.The public health administration North -Rhine -Westphalia, Bavaria, Baden -Wurttemberg, Lower was completely reorganized by a law of 1934 which Saxony, Hesse, Rhineland Palatinate, Schleswig -Holstein, Ham- provided for the distribution of health departments burg, Bremen and the Saar.West Berlin is not a formal in urban and rural districts in such a way as to secure member of the Federal Republic.By the end of 1955 the population of the Federal Republic of Germany was 50 000 000. much greater uniformity of the health services. West Berlin had 2 200 000 inhabitants and the Saar 992 000. Under a basic law passed in 1949 in relation to The capital, Bonn, had a population of about 141 000.The the structure of the Federal Republic the major population density of the Republic was 205 per square kilometre. powers in health services were given to the Lander. The net national production at factor cost in 1955 was re- ported to be equivalent to US X30 000 million, to which industry The Federal Government retained rights of concurrent contributed 44.6 per cent., agriculture and forestry 9.0 per cent., legislation in certain matters.Provisions for pre- and commerce and transport 8.4 per cent. ventive medicine and health education are included The cultural pattern of West Germany is Western European in the basic laws. and the educational level of the people is high.All children The national health administration consists of a between the ages of 6 and 14 must attend a recognized school. In 1954 there were some 30 000 primary schools, 2312 middle Federal Health Board, a Federal Health Office and and secondary schools, 8440 technical and about 1000 special, a Health Division in the Federal Ministry of the training and higher institutions.In 1953 there were 17 univer- Interior, with a Director - General in charge of the sities with about 77 000 students, 12 Catholic training colleges Division.The Federal Health Board is composed and seventechnicalcolleges.In round figuresthetotal primary school population was five million, secondary 1 200 000 of 80 persons, whose duty it is to advise the Govern- and technical over 2 200 000. ment on allpublic health matters.The Federal Public assistance is given to all who are unable to earn their Health Office is responsible to the Federal Ministry living.There are also insurance pensions, war and widows' of the Interior for carrying out research work in allowances, and unemployment relief.The total number of public health, medical statistics and narcotics control. persons insured under social health insurance in 1954 was 23 800 000, and 23 500 000 persons were insured under accident The Robert Koch Institute, the Max von Pettenkofer insurance enforced by law. Institute and the Institute of Water, Soil and Air 256 FIRST REPORT ON THE WORLD HEALTH SITUATION
Hygiene in West Berlin are also under the Federal rities or in scientific institutes, private business or Health Institute.In each of the Lander there is a in other institutions was 5084.Of the 67 602 active Health Division attached to the appropriate Ministry - physicians (3300 were retired on account of age or either the Ministry of Social Affairs or the Ministry marriage), 23 371 were qualified specialists.At the of the Interior -with the exception of the City Lander end of 1955 the total number of medical and health (West Berlin, Bremen and Hamburg), where a member personnel, including auxiliary personnel, active in the of the city council is made responsible for public country (including West Berlin) was 284 794. health.In addition,the Lander HealthServices At the end of 1955 graduate dentists numbered maintain close co- operation with other services, such 29 180.Nursing personnel, excluding those in train- as local education authorities, water economy boards, ing, numbered 116 101, of whom 11 877 were men. mining offices and social welfare and youth welfare Local authorities employed13 598 nurses. The offices, as well as medical bodies such as the German number of midwives was just over 10 000 and is Red CrossSociety,Caritas,the Home Mission declining.On the whole, there are about 23 nurses Society and the workers' welfare organization. of both sexes per 10 000 of the population. The local health offices are integral parts of Stadt- In the same period, 1610 full -time physicians and kreise (urban districts) or Landkreise (rural districts) 147 full -time dentists were employed in the 480 health which are the lowest administrative authorities.In offices of the Federal Republic.An increasing share some Lander such as Baden -Wurttemberg, Bavaria, in the health service is taken by the part -time prac- Lower Saxony and Rhineland Palatinate, the health titioners, who numbered over 3000 in 1955. offices are directly subordinate to the state health The number of hospitals at the end of 1955 was officer of the Lander, while in the Lander Hesse, 3353, with an additional 149 in West Berlin.In North -Rhine -Westphalia and Schleswig- Holsteinall the 3353 hospitals the total number of beds was the health officesare communal institutions sub- 530 096, the rate being 10.5 per thousand population. ordinatetoStadtor Landkreiseadministrations. The number of in- patients during the year was about The size of such districts varies, and the smallest 6.2 million, representing about 173 million patient comprises about 20 000 inhabitants.In 1956 there days.At the same time, the hospitals were staffed were altogether in the country 498 health offices, with 20 097 full -time physicians, 6892 general prac- including 12 in West Berlin.According to the Law titioners treating and attending their patients in the on the Unification of Public Health, promulgated on hospitals but not employed by the hospitals, 86 573 3 July 1934, the local health offices have the following nurses (male and female), 5060 midwives,15 116 specific functions: medico -technical aides, 17 967 personnel engaged in (1) General health administration including super- administrative work, and 105 048 in domestic duties. vision of the medical professions and hospitals, as The studentnurses,male and female, including well as of drugs and poisons, the control of epide- midwives working in the hospitals, numbered 16 347. mics, environmental hygiene, food hygiene, housing, The ratio of trained nursing staff to number of beds industrial and school health; was 16:100. (2) Public health education; There are in the territory of the Federal Republic 16 (3) The welfare of school children; faculties of medicine in universities, a medical academy (4) Maternal and child health; for physicians and an academy of medical research. The annual number of medical graduates was 2069 (5) Care of persons suffering from tuberculosis, in 1954, 1521 in 1955, and 941 in 1956.In the summer veneral disease,physicaldisabilities, drug addicts semester of 1956, there were 10968 medical, 1735 den- and the care of the chronic sick. tal, and 2723 pharmacy students in these institutions. The total health expenditure in 1955 of the Federal Training facilities for allied medical and health per- Government and the Lander (including West Berlin) sonnel available in the country in 1956 were as follows : was DM 2 017 254 000 (US $480 298 571), or 3.9 per Number Number cent. of the total expenditure.At the close of 1955 of institutionsof students Midwifery schools 21 338 there were 70 902 physicians (of whom 84.2 per cent. Maternity care training establishments 12 43 were men) in the country, including those not in Infant and child nursing schools . 127 3 389 practice.The number of general practitioners was Dietitian training schools 13 229 42 382, including 5793 women.The ratio of practis- Clinical (sick) nursing schools . . 458 10 082 ing general practitioners to the population including Schools of physiotherapy 34 1 026 Schools for medico -technical assistants 35 2 023 those in hospitals was 1: 805.In 1955 the number Schools for welfare and youth welfare of physicians employed full -time by public autho- workers 34 1 611 EUROPEAN REGION 257
The birth rates during the years under review tion, and during 1954 and 1955 immunizations were were: 15.7 in 1954, 15.7 in 1955, and 16.4 in 1956. carried out against cholera, yellow fever, typhus, The proportion of illegitimate births in 1955 was diphtheria, whooping- cough, typhoid fever, tetanus, 7.7 per cent.Stillbirths have remained at 2 per cent. rabies and tuberculosis (BCG). of the total births for some years.The death rate Maternal and child health activities include the for all ages, which averaged 10.5 during the years services offered by advisory centres for expectant 1950 -54, rose to10.8 in 1955, and 11.2 in1956. mothers at the health departments in the large cities, The infant mortality rate shows a steady improve- frequently combined with gynaecological clinics.At ment: 42.8 in 1954, 41.5 in 1955, and 38.4 in 1956. the infant welfare centres all infants are given vita- Neonatal death rates during the same period were min D preparations for the prevention of rickets. 28.9, 27.9 and 25.6.The maternal mortality rates At a later stage, health supervision is undertaken were 15.0 in 1954 and 16.0 in 1955. in the kindergartens.The following figures give an With the upward trend of expectation of life at indication of the extent of facilities at the end of 1955: birth there is a substantial increase in the number Number Places of old people in proportion to the total population; of establish- available 10 per cent. of the population was over 60 years of ments (in thousands) Infant nurseries 348 15.7 age in 1956. This figure raises special problems of Children's homes 1 045 71.5 medical and economic care of the age -group in question, Convalescentandrecreation the provision of special employment and housing homes for children and minors 919 53.2 playing an important role. Crèches 294 14.3 Kindergartens 10 853 738.0 The major causes of death in 1954 and 1955 were Collective nurseries reported as follows: (including day nurseries). . 1 196 63.8 1954 1955 Malignantneoplasms,includingneo- plasms of lymphatic and haemato- In the school health services, children are examined poietic tissues 92350 94729 as a rule in the first, fourth and eighth (last) school Arteriosclerotic and degenerative heart years, and children who need medical treatment are diseases 80675 87867 referred by the school doctors to the family physician. Vascular lesions affecting central nervous In the larger cities school health consultative ser- system 79665 83816 Senility without mention of psychosis, vices have been created for boys and girls attending ill- defined and unknown causes . . 41805 43279 vocationalcentres.Many of thehealthoffices Pneumonia 17596 18697 have set up clinics for dental health care especially Accidents 26497 28579 for schoolchildren.The main purpose is preventive, Unqualified diseases peculiar to early infancy and immaturity 16738 16054 and children found to have defects in the teeth or jaws are referred to local dental surgeons for treat- During the period under review, the numbers of ment. reportedcasesof certaincommunicablediseases The Federal Ministry of Labour is responsible for were as follows : occupational health at the national level.At the 1954 1955 1956 Lander level the work is associated with either the Tuberculosis 96103 91655 85562 Ministry of Labour or the Ministry of Social Affairs. Whooping -cough 41113 41014 38145 Factory inspection work iscarried out by State - Diphtheria 14358 11719 8232 Typhoid fever (including pa- appointed industrialphysicians, who are mainly ratyphoid fever) 5657 6594 4980 concerned with research and clinical work on occupa- Poliomyelitis 2713 2869 4109 tional diseases.There is no special health organiza- Syphilis (not including cases tion for the care of the chronic sick, but the functions in Lander of Schleswig - are distributed among the various branches of health Holstein and Bavaria) . . 8910 care,such as tuberculosis and mental disorders. Of the 530 096 hospitals beds available in the country The local health offices have definite responsibility in 1955, about 16 112 were allotted to cases of infec- for organizing and financing the care of those patients tiousdisease(excludingvenerealdiseases),and who have to be admitted to hospital.In the case 62 115 to tuberculosis patients. of old persons admitted to institutions the costs of Measures were taken to prevent certain infectious accommodation, medical fees etc. are borne by the diseases through active immunization of the popula- public welfare department. On the other hand, a tion.For example, smallpox vaccination was made considerable number of elderly people who require compulsory for both first vaccination and re- vaccina- medical and financial assistance are dealt with in 258 FIRST REPORT ON THE WORLD HEALTH SITUATION their own homes.In many cases they are provided were centrally supplied with water at the end of 1956. with a home nurse in order to avoid hospital admission. In 1954 over 61 per cent. of the people in the Federal Some health offices and clinics have established territory were served by public sewerage systems, advisory centres, conducted by psychiatrists, for the and a number of sewage plants which were destroyed care of the mentally ill.In 1955 there were 156 hos- during the war are under reconstruction. A law pitals with 92 009 beds for psychiatric and neuro- was enacted in 1955 to encourage the construction logicalcases,includingmania.Theeducational ofpurifyingplantsforindustrialwastes.The advisory centres, such as those for child guidance, Federal Government grants loans of up to 30 -40 per are served by special educators including psycholo- cent. of the cost of building purification plants for gists who work in close co- operation with parents household waste water for the purpose of further or guardians. improving the sources of water supply. Alcoholism and drug addiction have been dealt Housing conditions have improved considerably with by the German Centre against Alcoholism and asa result of intensive buildingactivities.The Drug Addiction, and in 1956 the Lander of North - number of dwellings showed an increase of 35 per Rhine- Westphalia reported a total of about 30 000 cent. between 1950 and 1956. alcoholics cared for by the advisory and welfare Systematic investigation of soil, water and other centres, compared with 24 000 in 1954.The number elements for radioactive substances are carried out of known drug addicts in the Federal Republic is to a limited extent by the Max Planck Institute of decreasing; in 1954 it was 5228; in 1955, 5106; and Biophysics,andregular measurementsof radio- in 1956, 4784. activity in the atmosphere are undertaken by the With regard to environmental sanitation it was meteorologicalstationsof the German Weather reported that about 83 per cent. of the population Bureau.
GIBRALTAR
Gibraltar is a rocky promontory, 426 metres high at its The following were the health personnel in the greatest elevation, connected by a low isthmus to the southern territory in1957: 34 registered physicians (seven end of Spain.It is about 23 kilometres from the coast of Africa.The area of the territory is about six square kilometres. government, two city council, and 25 private); nine At the 1951 census the resident civilian population was 23 232. dentists (one in government service); 22 nurses of At the end of 1957 the estimate was 25 403. senior training; 21 pharmacists (three in government Except for the Port Development Committee, there is no spe- service); 16 certificated nurses; 98 partially trained cial economic machinery.Plans are under way for the improve- ment of port facilities.There is no land suitable for agriculture nurses; 23 midwives of senior training; seven sanitary and no forests, fisheries or other natural resources.There is, inspectors; six laboratory technicians (all in city council however, a fish- and fruit -canning factory and some other small service). industries employing about 750 to 1000 people. The vital statistics for the civil population in 1957 Primary -school education is free and compulsory from 5 to were: birth rate, 21.6; death rate, 9.84; infant mortality 15 years and teaching is in English.There are also secondary and technical schools. rate, 16.33. The housing shortage, which began after the war, continues There is no medical school, and the medical staff to receive the close attention of the Government.The total are trained in the United Kingdom.Nurses who number of permanent dwellings erected between 1954 and 1957 desire to obtain the United Kingdom qualifications was 1110.Temporary dwellings totalled 423, and this number are sent to England for training, but there is a nurses' will continue to diminish as demolition of temporary structures makes way for permanent housing. training school which trains nurses for local registra- tion. In 1955 there was one general hospital with 147 beds, Health one hospital for cardiovascular diseases, with 60 beds, The Chief Medical Officer advises on medical a mental hospital with 60 beds, and an infectious matters apart from hygiene, sanitation and other disease hospital with 30 beds.There are no private public health measures which come under the control institutions.Ante -natalclinicsare heldtwicea of the Medical Officer of Health, who is employed week at the general hospital.There are three infant by the Municipality.In 1957, 12.6 per cent. of the welfare centres, and clinics are held twice weekly at total budget was spent on health. the town centre and once a week at the others. EUROPEAN REGION 259
The medical department provides child welfare, Red Cross Society which contributes to the welfare school medical and dental services.It is also respon- of patients. A successful blood transfusion service sible for a district medical service which includes free is also in operation. domiciliary and out -patient treatment for the poor Potable water is supplied by the City Council and and for government servants.In 1952 a scheme isderived from wells and rain catchments on the was started for free x -ray examination of prospective Rock.Water for sanitary flushing is pumped from employees.There is an active branch of the British the sea.
GREECE
The mainland of Greece is a peninsula jutting out from the accepted fact that, owing to the economic conditions south of the Balkans into the Mediterranean; itis deeply indented in several places by long sea inlets, and is surrounded by that have prevailed in Greece for over 40 years, it many islands.The country is mountainous, with fertile coastal has not on the whole been possible to organize a strips and wide plains, such as the plain of Athens, the two programme which will meet fully and effectively the valleys of Thessaly and the Salonika plain in Macedonia.The public health needs of the people.The continual area of the mainland is 107 000 square kilometres and that of influx of refugees as a result of war and natural the islands about 25 500 square kilometres.The climate is characteristically Mediterranean. disasters during this period has seriously undermined At the last census, in 1951, the population was 7 632 801, with Greek economy and affected the health development a density of 60 per square kilometre.It has been estimated of the country. that 29.2 per cent. of the population over 10 years of age are The latest change in the organization of the country's illiterate.Approximately half the population are engaged in health services took place in 1951, when a Ministry rural occupations and one -quarter are workers and artisans. Each department, or nomos, is under the charge of a prefect. of Social Welfare was set up and made responsible Since 1950 local government has been considerably strengthened, for both social welfare and health.Since 1956 this especially in revenue policies, with the help of the Ministry Ministry has comprised three Directorates -General: of Finance.In the year 1950 -for the first time since 1935 - Public Health, Social Welfare, and Housing.The every commune in Greece elected a council, which in turn chose one of its members as mayor. Directorate -General of Public Health consists of a Only one -fifth of the country's area is arable land, but this has central service and district services. to support nearly 54 per cent. of its working population; and The central service is divided into eight divisions farming is concentrated on special crops such as tobacco, and three sections, whose duties include public health, currants and olives in order to pay for essential imports such as social health, hospitals and medical care, tuberculosis meat, wheat and flour.Among the difficulties of agriculture are soil erosion and the insufficient use of fertilizers.There are control,sanitary engineering, malariaeradication, many small industries and a great variety of mineral deposits. supervision of the medical and para- medical profes- Production is generally in private hands. sions, rural social security, venereal diseases, trachoma, All children between the ages of 6 and 14 must attend school, and drug control.The districtservices comprise and during the past generation there has been a striking decline in illiteracy.In Athens there is a polytechnic school and a public health centres,training centres for health number of institutions for higher education, which teach such personnel and public health laboratories. subjects as agriculture, political science, economics and com- There are at present 52 district public health centres mercial science.Greece has two universities, one in Athens in operation, one in each department except Attica with 4500 students, and the other in Thessalonike with 2200. and the Dodecanese, each of which has two centres. During the war Greece suffered great damage to its roads, railways, bridges and ports.Normally about 90 per cent. of Every centre is staffed by a public health officer, one its imports and exports are sea -borne.In 1951 there were over or more health visitors and two or more sanitary 22 000 kilometres of roads and the total length of the railway inspectors.The staffs of the large public health system was 2679 kilometres of which about half was owned by centres (such as those in Athens, Piraeus and Thessa- the State. A national airline provides services within the country, and many foreign airlines connect Athens with the lonike) also include a number of specialists. principal cities of the world. The training centres attached to the district service of the Directorate - General of Public Health are: Health the School of Public Health of Athens, a school for health visitors, and three schools for midwives, three Since 1833, when a service known as the " Sanitary schools for nurses, three schools for auxiliary nurses. Police " was set up in the newly- created Ministry of The School of Public Health of Athens was founded the Interior, the national health administration of the in 1929 and trains public health officers, sanitary country has undergone numerous changes.It is an inspectors and health visitors. 260 FIRST REPORT ON THE WORLD HEALTH SITUATION
The Athens Public Health Laboratory is engaged The vital and health statistical services have been in microbiological diagnosis and research, analyses in the process of reorganization since 1945.During of water, milk and other foodstuffs, as well as in the the period under review, birth rates were 19.2 in 1954, production of vaccines.In addition there are two 19.4 in 1955 and 1956; death rates were 7.0 in 1954, centres in Athens, under the district service, for the 6.9 in 1955, and 7.4 in 1956; infant mortality rates production of smallpox and rabies vaccines.The were 42.3 in 1954, 43.5 in 1955, and 39.2 in 1956. health and microbiology laboratories in the Univers- The chief causes of death during the same period were: ities of Athens and Thessalonike, the Pasteur Institute all types of heart and vascular diseases, malignant of Greece and the microbiological laboratory of the tumours, infectiousdiseases,accidents, and other veterinary service, also produce sera and vaccines causes of ill- defined origin. and carry on research work. Before the war Greece was classified among the There is no uniform system in the country for the countries with the highest morbidity and mortality provision of medical care.Medical care services are ratesfor tuberculosis.In order to improve this made available in the hospitals, health centres, and situation, a tuberculosis division was established in dispensaries, and in the homes by provisions from the 1951 in the Ministry of Social Welfare.The number State,local authorities,social security funds, the of sanatorium beds was increased by 1550, and a National Institution for Social Welfare and Assistance, total of 7729 beds for the care of tuberculosis patients the Red Cross, and other public and private organiza- was thus available in 1956, exclusive of the army's tions.In 1956, for instance, 133 organizations of all 650 sanatorium beds.During the past four years the types provided hospital care with a total of 26 890 dispensaries of the district public health centres have beds.There werealso538privateclinicswith been giving care and treatment to indigent tuberculosis 8741 beds, and 82 communal public health centres patients, and providing them with drugs such as with six beds each.Thus approximately 36 123 beds streptomycin, PAS and dianicotyl.Between 1948 and were available for medical care services in establish- 1956, 2 900 000 persons were tested for tuberculosis ments of all types, most of which are in Athens.All and approximately1 680 000 were vaccinated with are under the supervision of the Directorate -General BCG. Mass x -ray examination of the population of Public Health. has been undertaken by the Athens Research Institute At the end of 1956 there were about 9500 medical for Thoracic Diseases and by its branch in Thessalo- practitioners in the country, almost half of whom were nike.From 1946 to the end of 1956 these institutions practising in Athens and Piraeus; most of the others examined approximately 1 300 000 persons of different were also concentrated in the larger cities.There is, population groups, of whom approximately 106 000 therefore, a shortage of both hospitals and practi- were found to be infected with tuberculosis.The tioners in most rural districts. microbiological laboratory of the Athens Research Out -patient medical care is provided in hospital Institute is also carrying out research work on thoracic dispensaries and in polyclinics in Athens and Piraeus diseases. as well as in certain municipalities and communes. Trachoma is present in endemic form.Owing to Treatment is also given in the various special centres the war and the influx of refugees, this disease increased forthe control of tuberculosis, venereal diseases, very much fifteen years ago, when its index for the trachoma, etc. In accordance with the 1955 Act on population as a whole was stated to be between 3 and Rural Social Security, medical care for the rural 3.5 per cent.Fifty to sixty dispensaries were sub- population (some 4 500 000 people) is being organized, sequently established to provide treatment for persons with priority given to the establishment of dispensaries suffering from trachoma and other communicable in remote mountainous and isolated regions.By the eye diseases. A special hospital with 57 beds was end of 1956, plans had been made for 1402 communal opened for the treatment of trachoma among orphans and rural dispensaries, of which 830 were already in and unprotected children.Although trachoma is operation. still prevalent in some of the islands and in the The Social Security Institution and various other northern districts of the country, where economic health insurance organizations and funds provide difficulties have prevented any measures from being domiciliary medical carefortheir members.In taken as yet, the disease on the whole is believed to accordance with the Rural Social Security Act, the be on the decline. State, through the Ministry of Social Welfare, must Malaria was prevalent in the country before the provide the rural population with home medical care war, but the large -scale control campaign with new by general practitioners and the staff of rural and insecticides initiated in 1946 has been most effective communal dispensaries. in reducing this disease.The number of cases reported EUROPEAN REGION 261 during the period under review was 16 000 in 1954, these homes are in Athens, with 520 beds, one in 12 000 in 1955, and 2700 in 1956. Thessalonike with 120 beds and one in Chios with 42 Poliomyelitis,typhoidandparatyphoidfever, beds.Beds for maternity and obstetrical cases are leprosy, undulant fever, measles, encephalomeningitis, also available in the general hospitals and in private diphtheria, scarlet fever, whooping- cough, mumps, maternity and gynaecological clinics.Five children's infectious hepatitis and bacillary and amoebic dysen- hospitals, with a total of 520 beds, provide treat- tery are quite common in certain parts of the country. ment for sick children; two of these hospitals are The prevention of communicable diseases and the located in Athens, and provide between them 360 control of epidemics is one of the chief concerns of the beds. Directorate- General of Public Health.Two hospitals The School Medical Service is under the adminis- for communicable diseases have been established in tration of the Director of School Hygiene of the Athens and Thessalonike, with a total of 500 beds, MinistryofNationalEducationandReligious and the various general hospitals have also set aside Matters. A school canteen programme has been in beds for such cases.There are, furthermore, four operation for the last two years, providing 600 000 leprosaria, with a total of 687 beds, in Athens, Crete schoolchildren yearly with a school breakfast consis- and the islands of Samos and Chios. ting of milk, butter and cheese, which gives them The 52 district public health centres are giving 750 calories.Likewise, 135 school holiday establish- attention to the improvement of water supplies and ments, well located and equipped, receive annually sewage and garbage disposal, and to environmental some 60 000 children selected on the basis of health sanitation in general. A section for health education and certain social considerations. of the public was set up in the Ministry in 1952 and The number of beds available for persons suffering is disseminating health knowledge among the popula- from mental diseases seems to be inadequate, although tion by means of pamphlets, broadcasts, films and the number of cases of mental illnessin Greece lectures.Preventive inoculations and vaccinations is not exactly known.The Ministry of Social Welfare have also been carried out on a wide scale. has set up a committee of experts to study the various Maternal and child health is to a great extent the aspects of the problem and to draft legislation pro- responsibility of the National Institution for Social viding for the organization of mental health services Welfare and Assistance (PTKPA), which was esta- on modern lines. blished in 1929 and is now under the administration Other plans for the future development of the of the Directorate -General of Social Welfare in the public health services include: reorganization of the Ministry of Social Welfare.This institution has set Directorate -General of Public Health and develop- up some 80 MCH clinics in different parts of the ment of the public health and preventive functions of country.Mother and child health care during the the sections concerned; extension of hospital facilities; ante -natal and post -natal period, and during infancy co- ordination of all public health work; speedier and pre -school and school age is also provided by development of rural sanitation; and implementation the public health centres.There are four maternity of a large -scale programme for the eradication of homes in the country with a total of 682 beds; two of malaria.
HUNGARY
The People's Republic of Hungary is a'country enclosed in The population of Hungary in 1957 was 9 812 000. the centre of Europe, bordered by Czechoslovakia, the Union School attendance is compulsory for children between the of Soviet Socialist Republics, Romania, Yugoslavia and Austria. ages of 6 and 14.There are universities in Budapest, Pécs, It has an area of 93 030 square kilometres. Szeged, Debrecen, Miskolc and Veszprém, and the Hungarian The largest river in the country is the Danube which divides Academy of Science is in Budapest. it into two main regions : to the east, the Great Plain (Nagyalfold), Before the war the Hungarian economy was primarily agri- which is the most fertile part of Hungary; and to the west, the cultural, but in recent years industrial production and mining Transdanube (Dunántul), a region of hills and mountains. have grown considerably in importance.Most of the industries Among these mountains lies Lake Balaton, which has many and communications are owned by the State, which directs a holiday resorts along its shores.The climate of Hungary is planned economy for the country. continental; winters are comparatively cold, and summers Hungary isdivided, for administrative purposes, into 19 are hot. departments and four departmental municipalities in addition 262 FIRST REPORT ON THE WORLD HEALTH SITUATION to the capital, Budapest.The municipalities are further divided At the local level, the Health Offices, under the into districts, while the departments are made up of cantons municipal or departmental councils, act as the local and rural communes. There are 10 272.2 kilometres of railways.Highway and river health administrations.Each Health Office is under transport (the latter by the Danube) is also well developed the charge of a chief medical officer assisted by a throughout the country. A national airline runs civil transport second medical officer and a public health nurse. services from Budapest airport. The chief medical officers work in close liaison with various social organizations and have a great variety Health of health functions. At the end of the war, the administration of public Under the departmental Health Office there are health services in Hungary was shared by several various establishments,suchasthe departmental government departments, the Ministry of the Interior hospital, the polyclinic, sanitary and epidemic pre- being the authority mainly responsible for health vention stations, dispensaries for various types of matters. specialistservices(suchastuberculosis,venereal The health services in the People's Republic of diseases,neuropsychiatry,and cancer),nurseries, Hungary are now directed at the central level by a training schools or courses, blood banks, centres for unified national health administration - the Ministry physical education and sports medicine, and social of Health.The Minister of Health is the authority services. with supreme responsibility for the public health In the districts there are Health Sections, under services of the country.In addition to the secretariat the direction of district medical officers assisted by and personnel service, the Ministry comprises the medical hygienists and public health nurses, responsible following seven departments :medical and para- forallhealth matters inthe area.The district medical training establishments; curative and pre- medical officer directs and supervises the work of ventive medicine; maternal and child health; health hospitals, the occupational medical stations, the poly- inspection and epidemiology; planning, finance and clinics,dispensaries and child and school health investment; pharmaceutical and medical equipment services within the area.Medical hygienists attached services, and social affairs. to Health Sections deal in particular with all matters There is a Scientific Medical Council in the Ministry, relating to the control of epidemic diseases, environ- composed of the leading scientists in medicine and mental sanitation, town planning, and water supply. public health, to advise the Minister on the planning, General curative and preventive services are provided organization and administration of national health by the medical officers in the divisions.There are programmes. 3000 divisions in the country, each with a population Under the direct supervision of the Ministry of of between 2600 and 3500. Health are the schools of medicine, the Institute for At the end of 1956, there were 13 332 physicians in Advanced Medical Training, the specialized scientific Hungary (excluding those in the armed forces), of institutes and various national establishments, such whom 7514 were specialists.Of the total number, ashospitals,sanatoria,ambulanceservices,and 92.3 per cent. were in full -time government service, biological and pharmaceutical production centres. and 44 per cent. were resident in Budapest.There In addition, the services of the following 17 scientific were also 29 850 para- medical personnel, including institutesareavailableinthecountry: National 15 711nurses, 3498 midwives, 6239 medical and Public Health Institute; National Occupational Health laboratory assistants and other auxiliary personnel. Institute; National Food Hygiene and Nutrition Expenditure on cultural, health and social activities Institute; Koranyi National Institute of Phthisiology; as a whole represented 27.3 of the total State budget National Institute of Dermatology and Venereology; in 1956, compared with 21 per cent. in 1954. National Cancer Institute;NationalInstituteof In 1956, there were in Hungary, 46 national hospitals Neurology and Psychiatry;National Instituteof of various specialties, 25 departmental hospitals and Surgery of the Nervous System; National Institute of 77 municipal or cantonal hospitals, with a total of Rheumatology and Balneotherapy; National Institute 63 752 beds.Most of these hospitals are directly of Physical Culture and Sports Medicine; National under the supervision of the Ministry of Health.The Institute of Radiology; National Institute for the 56 university clinics attached to the four medical Control of Trachoma; National Institute of Trau- faculties provide 7564 beds, which are included in matology; Central Research Institute of the National the above total.The capacity of a cantonal hospital Blood Transfusion Service;National Instituteof varies from 100 to 300 beds, that of a municipal Kinesitherapy and Mechanotherapy; Central Institute hospital from 200 to 400, and that of a departmental of Radiobiology, and Central Institute of Stomatology. hospital from 400 to 800.There are also five tuber- EUROPEAN REGION 263 culosis sanatoria and eight convalescent homes for cough), between 6 and 11 months; smallpox vaccina- patients who still require some care after discharge tion, between 12 and 17 months; a second triple from hospital. A total of 1 150 000 persons received vaccination, between 18 and 23 months; and anti - hospital treatment in 1956; the case -fatality rate in typhoid and paratyphoid vaccination, at 12 years. hospitals was 2.1 per cent., and the average duration Re- vaccinations for smallpox, typhoid and paratyphoid of hospitalization was 17.3 days. are also compulsory. At the end of 1956 there were 116 mobile health The sanitary and epidemic prevention stations are services for the rural population. also carrying out programmes for the control of Some 6 300 000 inhabitants (64 per cent. of the brucellosis in agricultural undertakings, of helmin- total population) were entitled to medical assistance thiasis among schoolchildren, and of ankylostomiasis in1956 under thesocial insurance scheme.All among miners. paid workers and their families participate in this The National Cancer Institute is responsible for the social insurance, and the same applies to pensioned organization of all cancer control activities; at the persons,students,apprentices,artists and priests. end of 1956 there were 32 cancer control centres in Members of agricultural and workers' co- operatives, Hungary.In 1955, about 11 000 cancer cases were as well as independent workers and their families, treated in hospital. may also join the insurance scheme if they wish, but Persons suffering from trachoma in its infectious itis not compulsory.Persons insured under the form are obliged to go to hospital, and treatment, scheme are entitled to medical treatment and to as well as periodical eye examinations to detect this reimbursement of a certain proportion of the price disease, is provided free of charge by the State. of medicaments; some medicaments, however, are At the end of 1956 there were 23 centres dealing provided free of charge (in the case of communicable with neurological disorders. diseases, tuberculosis, etc.). Medical supervision of students engaging in physical The following vital statistics were recorded in 1957: culture and sports is carried out by the National birth rate, 21.2; death rate,11.1; infant mortality Institute of Physical Culture and Sports Medicine. rate, 59. Similar institutes exist in five large provincial towns. The centre of tuberculosis controlactivitiesis Maternal and child health activities are the res- the Koranyi National Phthisiological Institute.Any ponsibility of the State, and maternity homes and person suffering or suspected of suffering from tuber- health centres have been specially organized for this culosis in Hungary is required by law to undergo purpose.The Labour Code prohibits the employ- treatment, and physicians are required tonotify ment of pregnant women in work which may prejudice such cases.Of some three million persons who the normal courseof pregnancy;twelveweeks' undergo medical examinations in the dispensaries every paid leave spread over the period before and after year, about 0.3 per cent. are found to be suffering from confinement are stipulated, and various facilities are tuberculosis.The dispensaries are also responsible accorded to mothers feeding their infants. for the organization of BCG vaccination.In 1956, At the end of 1956, 6443 beds were reserved for 29 232 cases of tuberculosis were detected and regis- confinements and gynaecological cases in hospitals, tered, and a total of four million consultations were and in the districts without hospitals there were given in the 184 tuberculosis dispensaries. 99 maternity homes, with a total of 1050 beds.At The control of venereal diseases is centralized at each health centre there are midwives and public the National Institute of Dermatology and Venereo- health nurses who attend home confinements and logy.At the end of 1956, there were 129 dermatolo- give health care to the infants; in 1956, 3498 midwives gical dispensaries in the country, which dealt with and 200 public health nurses were employed in about four million persons. Some 19 per cent. of these 1477 health centres. were treated for venereal diseases in special control Sixty -three per cent. of confinements in the provinces units. in 1956 took place in maternity homes; in Budapest No cases of cholera or smallpox have been reported thepercentageof institutionalconfinements was in Hungary for several years.In Budapest there is 99.2, and the average for the country as a whole was a special hospital for communicable diseases.In 67.9.The maternal mortality ratein1956 was 1956, 3521 beds were available in the country for this estimated at 0.5.About 80 -85 per cent. of infants purpose. are cared for in the special clinics attached to the The following vaccinationsarecompulsory in health centres, and there isa special hospital for Hungary :BCG vaccination,withinsix weeks of prematureinfantsinBudapest.In1956,every birth; triple vaccination (diphtheria /tetanus /whooping- infant received an average of 11.5 visits by a nurse. 264 FIRST REPORT ON THE WORLD HEALTH SITUATION
In 1955, 312 000 litres of mothers' milk were dis- patients.Thereisa provincialneurological and tributed free of charge from thirty -two milk stations. psychiatric hospital, and psychiatric sections in depart- Day nurseries are provided for the children of working mental, municipal or cantonal hospitals, with 6243 mothers and at the end of 1956 there were 716 such beds in all.There are three mental homes and three nurseries, accommodating 25 630 children, attached to treatment clinics for mild cases.For mental patients the local councils and the factories. remaining with their families, regular surveillance is The school medical service in Hungary employs carried out by the neuropsychiatrie dispensaries. 260 full -time physicians, and all schools with 2000 There are four faculties of medicine in Hungary, pupils or more are provided with a full -time school attached to the universities of Budapest, Szeged, medical officer.At the end of 1956, there were Pécs 'and Debrecen.At the University of Budapest, 6369 hospital beds for sick children, excluding beds in addition to the Faculty of Medicine there is a for contagious and tuberculous cases; beds for children Faculty of Odontology and Stomatology and a suffering from tuberculosis during the same year num- Faculty of Pharmacy; the Szeged University also has bered 1743.There is a school dental service with a Faculty of Pharmacy. a staff of 250 dentists. In 1956 the four medical faculties had a total The Ministry of Health has a special department for teaching staff of 1147, composed of 104 professors, healtheducation.Among schoolchildren,health 141 lecturers, 167 deputies and 735 assistants.Can- education is given by teachers and by the staff of the didates for admission to the university must be in school medical services.For the general public, possession of a secondary school certificate and must each medical officer is responsible for carrying out pass an entrance examination.In the academic health education as part of the joint programme of the year 1956 -57, 1041 students were admitted to the Ministry of Health and the Hungarian National Red first year of the medical course, 74 to odontology and Cross Society.Lectures and conferences on health stomatology, and 248 to the pharmacy course; the education are also given under the auspices of the total student body at all stages of the three courses Society for the Diffusion of Natural and Social was 5667.The medical course lasts six years, dental Sciences. surgery fiveyears, and pharmacy four and a half In Hungary, the State is responsible for industrial years.On completion of university training, students health services, and the National Institute of Industrial take a State examination.In the hospital services, Hygiene is the technical authority established for this appointments are made on a competitive basis. purpose.Factories employing 500 workers or more It is possible to qualify as a medical specialist are provided with a regular medical service, and in in three or four years, according to the specialty. the large undertakings specialized consultation services In 1956, 609 students qualified as doctors of medicine are also available.At the end of 1956 there were and 608 as specialists.In addition to the specialist's 630 occupational medical officers working at various diploma courses, there are short refresher courses industrialestablishments.TheInstituteforthe in the various branches of medicine for medical and Health Protection of Apprentices carries out systematic health officers in both clinical and public health work. medical examinations on recruitment and at regular Para -medical staff are trained either in special intervals thereafter. schools or by in- service training.In 1956, there were The Social Service concerns itself with chronic the following schools for para- medical personnel: invalids, war invalids, physically handicapped persons, Number Number and the mentally disordered.All persons whose Type of school of schools of students invalidity is due to occupational accident, and whose Public health nursing 3 650 incapacity is 67 per cent. or more, receive an invalidity General nursing 10 1 100 Paediatric nursing 8 pension. 470 allowanceor Two hospices have been Midwifery 6 300 opened for tuberculosis patients, with 205 and 80 beds Child care nursing (nurses for respectively, and there are hostels, with a total of crèches and day -nurseries) . . 8 340 5000 beds, for chronic cases who have no family. For children with mental disorders and for the blind Certificates are issued to auxiliary personnel who there are five farm schools and six special establish- have undergone in- service training;1010 persons ments.At the end of 1956 there were 177 homes for were awarded certificates in 1956. the aged, with a total of 17 000 beds, catering for The National Public Health Institute and the pensioned workers without families. National Food Hygiene and Nutrition Institute are The National Institute of Neurology and Psychiatry responsible respectively for the control of pharma- islargely responsible for the care of psychiatric ceutical and food products.The Department of EUROPEAN REGION 265
Health Inspection and Epidemiology, in the Ministry systems for the disposal of wastes, the percentage being of Health, deals with all matters relating to environ- 28.9 in Budapest and 11.4 in other cities. mental sanitation and hygiene.In the departments There are 45 mechanical installations in the country or municipalities, these matters are dealt with through for the purification of waste waters, and strict regula- the sanitary and epidemic prevention stations, of tions are in force for the control and prevention of which there were 24 at the end of 1956, with 192 pollution of surface waters. medical officers on their staffs.Each of these stations As regards achievements in town planning and has a section for public health (environmental sanita- housing, between 25 000 and 30 000 apartments have tion, food control and industrial hygiene) and epidemic been built annually for the past few years. prevention, a laboratory section and a disinfection All workers in the food supply industries and other section. establishments dealing with food, including restau- Forty -four towns are provided with water -supply rants, are required to hold a health certificate and to systems, and in 1954 it was estimated that 56.1 per undergo regular medical examinations.The control cent. of the urban inhabitants were served by conduits. of food supply establishments from the health stand- The percentage in Budapest was 81.1.There are point is conducted by the sanitary and epidemic 49 water- distribution plants for villages, and 300 water - prevention stations.The laboratories attached to supplyestablishmentsinindustrialundertakings. these stations carry out all chemical and microbiolo- There are about 20 000 public wells of which some 20 gical examinations required, and in 1956 their staffs per cent. are artesian.In 1954 an average of 16.6 per included 386 medical specialists and 748 laboratory cent. of the inhabitants were served by drainage assistants, in addition to auxiliary personnel.
ICELAND
Iceland is a large island in the extreme north Atlantic, one of and one of navigation, a commercial high school and several the most volcanic regions of the world.With its tip just other specialized institutions.The University of Reykjavik was touching the Arctic circle, it extends from 63° to 67° north inaugurated in 1911. and from 13° to 25° west.Iceland is a plateau of volcanic Although possessing no railways, Iceland has over 5500 kilo- rocks pierced on all sides by fjords and valleys.The lowlands metres of roads, mostly fit for motor vehicles. Two companies -about one -fourteenth of the total -are almost the only provide regularairservices between Reykjavik and other habitable parts.Three -quarters of the area consists of elevated places in Iceland.There is also a regular air service to other deserts, lava streams and glaciers; the glaciers and snowfields countries in Europe and to the United States of America. alone occupy 13 per cent.The total land area is 103 000 square A new social welfare scheme came into force in 1947.In kilometres. 1956 nearly 93 000 contributors (apart from children) were The population at the 1950 census was 143 973, with a density covered for sickness and maternity benefits, 149 000 for medical of one per square kilometre, and the annual rate of increase at care, and (in 1955) 45 000 for occupational accidents. that time was about 2 per cent.The 1956 estimate was 162700. Nearly 73 per cent. of the population is urban.The island has five divisions: the South -West (80 623 inhabitants -the most Health densely populated); the Western Peninsula (11 166 inabitants); the North (28 632 inhabitants); the East (9705 inhabitants); Organized medical services in Iceland date back to and the South (13 847 inhabitants).Reykjavik, the capital, 1760, when the first medical officer was appointed. had a population of 65 305 in 1956.Iceland's traditions are Before that time, however, from about the middle of Scandinavian and the general educational level is high. the 17th century, small leper institutes had been Ministries in the Cabinet include Justice and Education, and Agriculture and Social Affairs.For administrative purposes established, one in each of the four main parts of the Iceland is divided into 16 provinces, each governed by a chief country.Leprosy was very prevalent at that time. executive.Each province forms one or two municipal districts Almost simultaneously with the appointment of the with a council superintending the rural municipalities.There first medical officer, the first trained midwife arrived are also 13 urban municipalities, each with a town council, and shortly afterwards a dispensary run by a qualified independent of the provinces. The main industries are fishery and agriculture.There is a pharmacist was established.The first task of the high production of electric power, most of it hydro -electric. medical officer was to teach medicine to students who The chief exports are fish, oils, sheepskins and mutton.Cereals were to take office as physicians, one in each of the and sugar are imported. four parts of the country.Soon afterwards the train- Primary education is compulsory for a period of nine years. There are three grammar schools, several public high schools, ing of midwives was begun and since then there has two girls' schools, and a school for primary school teachers. been a continuous evolution of the health service, For technical education, there are two schools of agriculture although progress was slow for the first hundred years. 266 FIRST REPORT ON THE WORLD HEALTH SITUATION
The Althing (parliament) took a great interest in the local authorities and the local sickness insurance health matters and made further progress in 1874, fund.The whole country is divided into 55 medical when it obtained legislative powers. A medical school districts, each served by a governmental district physi- was established in 1876 and in 1911 was merged into cian.Reykjavik is the only exception: it has a full - the University of Iceland as the Faculty of Medicine. time public health officer who is appointed and paid Since Iceland obtained full constitutional indepen- by the town council.District physicians have a dual dence in 1918 the development of public health and responsibility; as medical officers they are in charge social welfare- especially social security, organized of all public health work but at the same time they medical care and preventive medicine -has progres- carry on general practice.In the smaller districts the sively advanced.This progress is demonstrated by a district physician is the only doctor and the care of the great improvement in health conditions.Leprosy and sick occupies the greater part of his time.In the hydatid disease, previously very prevalent, have now bigger urban districts he is mainly concerned with been almost entirely eradicated and in the last 25 years preventive work and the curative services are taken the death rate from tuberculosis has fallen from about over by private practitioners, specialists and hospital 200 to less than 10 per 100 000.Cardiovascular and doctors. malignant diseases now account for most of the deaths, The first general hospital was established in Reyk- but next in order come accidents.Expectation of life javik in 1866, the funds having been raised by a at birth has increased by more than 33 years in the voluntary body.Six years later another voluntary past century.Its figure in 1946 -55, was 69.4 for hospital was erected in Akureyi, the main town of the men and 73.5 for women. north.Both of these hospitals were subsequently The supreme authority in all health matters is the taken over by their municipalities, and since then all Ministry of Health, headed by a Minister who holds general hospitals have become the primary responsi- other offices in the Government.At the side of the bility of the communities.The State is responsible Minister is the Director of Health, a medical expert for special hospitals (sanatoria, psychiatric hospitals, who holds a permanent post and who is in charge of etc.) intended to cover the needs of the whole country. both medical and auxiliary personnel.Some branches One general hospital -the State hospital at Reykjavik, of the health service, such as tuberculosis and school connected with the University-is,however, the health work, are placed under the immediate super- teaching hospital for medical students, nurses and vision of a special medical director. midwives. The State insurance institution (under the Ministry In 1955 the total number of hospital beds was 1615, of Social Affairs) is directed by an executive council, or 10.1 per 1000 of the population.Of this ratio, 6.5 the members of which are elected by Parliament. This were in general hospitals, 1.6 in sanatoria and 1.5 in a institution is responsible for administering accident psychiatric hospital. insurance, old -age and disablement pensions, unem- The situation with regard to health personnel in ployment insurance and, so far as health insurance is 1955 was as follows: 179 doctors in active practice; concerned, the supervision of local sickness insurance 44 dental surgeons; 19 pharmacists; 186 nurses holding funds.All health matters are in the hands of medical a diploma; 80 student nurses; 168 midwives; and experts on the staff.The Ministry of Social Affairs 14 veterinary surgeons. also deals, under a separate governmental office, with The medical faculty of the University of Iceland assistance to patients suffering from chronic diseases. includes schools of medicine, dentistry and pharmacy. Management of State hospitals is conducted by the The State hospital in Reykjavik also has schools of State Hospital Office under a Board appointed by the nursing and midwifery.The annual numbers of Minister of Health. Among other bodies connected students attending these institutions are: medicine, with health are a council of nutrition and a medical 200 -220; dentistry, 20; pharmacy, 10 -15; nursing, 95- council, both of which function in a consultative capa- 100; and midwifery, 12. city.The municipal and communal councils are Population statistics are worked out by the sta- responsible for environmental sanitation, supervision tistical bureau.The Medical Director of Health being carried out under local committees of which the issues an annual report containing morbidity and other district physician is a member and the expert adviser. statistics. These local authorities are also responsible for the The birth rate in 1956 was 28.3, the death rate 7.2 municipal or communal hospitals and for any health and the infant mortality rate 17.3 centres.The Treasury, however, gives considerable The cost of medical care is met by the sickness insur- financial support to hospitals and the running cost ance system, either by special arrangements made with of health centres is shared equally by the Treasury, medical societies or on the basis of an official tariff. EUROPEAN REGION 267
In the case of chronic diseases, including tuberculosis, care of poliomyelitis patients, and a rehabilitation the State takes over responsibility after the first five home for alcohol addicts, all run by voluntary bodies. weeks.Similar arrangements are made for the health Health education is begun in the primary schools care of the aged.There is as yet no mental health and continued in the secondary.District physicians service.The patients themselves pay little more than and the staff of health centres carry on health educa- a token amount for each consultation.There are tion of the public to a further extent, and health pro- 200 districts for midwives, and the intention is to paganda material, in the form of periodicals, for appoint one to each district except in the larger towns example, is published by the Red Cross; there is no where several midwives are appointed.As communi- centrally organized service. cations improve in the more remote areas, however, it Health centres have been established in most of the becomes increasingly feasible for one midwife to serve towns; their main activities are in the prevention of two or more districts.Midwives appointed in towns tuberculosis and in maternal and child care.The receive their salaries from the municipality, whilst those sickness insurance system provides medical care at in the rural districts are paid partly by the Treasury home as well as in hospital.At the health centre in and partly by the county council.In addition to their Reykjavik and in some other towns there are special fixed salary the midwives receive payment according departments for the examination of expectant mothers. to an official tariff for services rendered. Under the sickness insurance system every mother Practically all the qualified nurses in employment receives a specified sum after delivery, whether at home are working in hospitals or as health nurses in schools or in hospital.Every woman in official employment and at health centres.Local authorities in rural is entitled, after delivery, to 90 days' maternity leave districts are entitled to a substantial contribution from with full pay. the Treasury towards the cost of a district nurse's Supervision of environmental and working condi- salary. tions in factories, workshops and other work places is In Reykjavik and some of the larger towns, dental under the charge of a chief inspector, who is an en- surgeons are employed at elementary schools but gineer.Apart from this centralized supervision, the otherwise they are all in private practice.For vet- district physician is responsible for all matters con- erinary work the country is divided into nine districts. cerning occupational health. In all towns and some of the larger villages, there are A central piped water supply serves all the towns pharmaceutical dispensaries run by licensed chemists, and the larger villages, giving a total supply to ap- but in the smaller areas where there is no dispensary proximately 80 per cent. of the population.In the the district physician undertakes this work.There rural districts where there is no communal water are very few private health institutions and most of supply, the majority of households have their water them are subsidized.For example, there are three carried in pipes into the houses.All the towns and hospitals owned and run by foreign Catholic orders, larger villages have a closed sewerage system carrying a rehabilitation centre for convalescent tuberculosis the sewage out to sea.Apart from the small hospital patients erected by an association of former patients, laboratories, there are special laboratories in the and a cancer diagnostic centre, a clinic for the after- medical institutes, serving the entire country.
IRELAND
Ireland lies on the north- eastern edge of the Atlantic Ocean The general level of education is high.The main occupations immediately west of the island of Britain.It consists substan- are: agriculture, employing 446 000; manufacture, employing tially of a central basin surrounded by mountains; this central nearly 200 000; and commerce, employing 151 000. plain extends to the sea in places, notably in the east between Among the Ministers in the Cabinet are those for Health and Dublin and Dundalk.It has many valleys with good fertile Social Welfare, Agriculture, and Education. land. On the rugged western coast, however, agriculture is The chief local authorities are the county and county borough difficult because of the abundant rain and the shallow soil. councils, which are responsible for the general administration The climate is maritime and mild but subject to heavy rains of their respective areas.There are 27 administrative counties brought by the prevailing south -west winds. and four county boroughs, which have a status similar to that The area of the Republic is 70 282 square kilometres and its of the counties.The administrative counties include the urban population at the 1956 census was 2 898 264, with a density of districts, which are separate sanitary areas.Each district is 41 per square kilometre. The capital, Dublin, has a population of governed by an elected council responsible for environmental 539476.About 59 per cent. of the inhabitants live in rural areas. services such as housing, urban roads, etc.There are 60 urban 268 FIRST REPORT ON THE WORLD HEALTH SITUATION sanitary districts, including the four county boroughs, seven development of voluntary hospitals, the provision of municipal boroughs, and 49 other towns. hospital services by the local authorities was on a The economy is primarily agricultural.The chief industries are grain -milling and baking, dairy products and bacon curing, comparatively small scale. brewing, sugar and confectionery, wool and worsted clothing, The generalpractitionerserviceforthe poor soap and candles, constructional materials, engineering and originated in the Poor Relief (Ireland) Act of 1852, implements, and the manufacture of linen, cotton, jute and which provided for a staff of medical officers and canvas. Elementary education is free and compulsory and is given in the establishment of dispensaries throughout the national schools.The secondary schools are in private hands country. To this, a dispensary midwife service was and many of them are run by religious orders with the aid of later added.At first the keeping of registers of Stategrants.There aresixState -aidedtraining colleges. births, deaths and marriages became the responsibility Vocational schools are controlled by the local vocational edu- of the dispensary doctor; in later years he was charged cation committee and are maintained partly by local and partly by central grants.Winter agricultural classes for the sons of with public health duties -especially the carrying -out farmers are provided by statutory committees of agriculture. of vaccinations against smallpox. The centresof universityeducation areTrinityCollege, The organization of health services by the sanitary Dublin, and the National University of Ireland.Founded in authoritiesreceiveditsimpetus mainly from the 1909, the latter has four constituent colleges -the University 1878. Colleges of Cork, Galway and Dublin, and St Patrick's College, Public Health(Ireland) Act of This Act Maynooth. provided for the creation of local sanitary authorities The principal ports are Dublin, Cobh, Dun Laoghaire, Cork, throughout the country, for the notification of infec- Galway, Waterford, Rosslare, Limerick and Dundalk.There tious diseases and for the supervision of food.The are 900 kilometres of inland navigation.The length of railway appointment of local medical officers of health was in the Republic is 4390 kilometres of which 90 per cent. is standard gauge.In 1951 -52 a total of 80 000 kilometres of road initiated.Later, these sanitary authorities became was maintained out of local funds, including 16 000 kilometres responsible for the provision of maternity and child of main roads and 62 000 kilometres of county roads.There care services.Other local authorities were given the is a national air service which operates over a wide area. task of setting up services to combat tuberculosis Shannon in the south -west is a starting and landing point for transatlantic traffic. and to deal with the medical inspection of school- Social welfare services concerned primarily with income children. maintenance were unified in 1953 under the Minister of Social In spite of the restrictions imposed by so many Welfare, whose Department deals with both insurance and differentauthorities legal therewas assistance schemes.The Social Insurance Scheme, which is maintained by approximately equal contributions from the considerable expansion of the services during the worker, the employer and the State, provides unemployment first half of the 20th century.The preventive ser- benefit, disability (sickness) benefit, marriage benefit, maternity vices, especially, made headway, and their organiza- benefit and widows' and orphans' pensions.Assistance services tion was encouraged by the appointment, under an consistof non -contributory widows' and orphans' pensions, Act of 1925, of county medical officers of health old -age pensions at 70, pensions for the blind, unemployment assistance and children's allowances.In 1954, 686 000 persons throughout the entire country.The dispensary medi- were covered for sickness, invalidity and maternity benefits, and cal service was also developed to provide a good 728 000 for survivors' pensions. general practitioner scheme for the lower income groups.In the years since the end of the Second Health World War considerable progress has been made in improving the services and in simplifying the admin- The development of health servicesin Ireland istration.Many new hospitals have been provided proceeded during the 19th century along two parallel and several existing ones have been extended.The lines.The curative services for the poor were de- service for the prevention and cure of tuberculosis veloped as part of the Poor Law system and at the has been greatly expanded and new laws have been same time preventive services were organized by introduced tocontrol infectiousdiseases and to sanitary authorities under the public health acts. improve the system of food hygiene.Practically all The Poor Law Code of Ireland, as embodied in the the health work is now discharged by the county Poor Relief (Ireland) Act of 1838, provided mainly councils and city corporations.The categories of for the workhouse system to cater for the sick poor; people entitled to avail themselves of hospital and infirmaries were attached to the workhouses.In the maternityserviceshave been widened and new course of time these formed the basis of the general services have been provided for the rehabilitation hospital services throughout rural Ireland and in of the disabled.The general policy of the Irish the latter part of the 19th and the early part of the Government in the matter of health servicesis, presentcenturyseparatehospitalsforinfectious first, to provide adequate and efficiently organized diseaseswerebuilt.In Dublin, becauseof the services to prevent the spread of infectious diseases, EUROPEAN REGION 269 to safeguard food supplies and to avoid conditions The responsibility for registration of births, deaths harmful to the public health;secondly, to make and marriagesrestswiththeRegistrar -General, curative and restorative services available, free of who is an officer of the Ministry of Health.The charge, to the people who cannot readily afford central department also deals with health propaganda to pay for private medical care, and to encourage and the building of sanatoria. others to avail themselves of similar services on the There are no regional health authorities in Ireland. basis of partial or full payment. The local health authorities (the county and county In promoting the second of these aims, the principle borough councils) operate under the direct control is to consider each type of service separately.For of the Minister, each Council having a manager example, the general medical service provided by who acts as its chief executive officer.The staff health authorities is limited to the lower income of the health authority includes a county or city group because the expense of paying a private practi- healthofficer, and various medical and auxiliary tioner out of income is not a severe hardship for personnel.Each local area has a consultative health higher income groups; but hospital and specialist committee appointed by resolution of the county services and maternity care, which are more expensive, council; it consists of members of the council, the are provided on a free or subsidized basis to a much county medical officer, the county surgeon, two other wider group comprising about 85 per cent. of the medical practitioners and two other persons.The people.For persons outside these groups the State committee advises the manager on his functions in encourages services throughvoluntaryhealth the health field.The county, which is the basic insurance. health unit, serves on the average a population of The Minister for Health, who is a member of the 84 000.Within each county there are an average Cabinet, is in charge of the health services at the of 22 dispensary districts, which are the units for the national level.His responsibilities include the super- general practitioner medical services. vision of local authorities in carrying out their health Local health authorities provide, free of charge, functions, and the provision and administration of a general practitioner service including drugs, ophthal- funds to meet part of the cost of building and maintain- mic and aural treatment, and medical and surgical inghospitals,sanatoria,dispensariesandother appliances for persons who are unable to meet the institutions and of operating the services.Many cost of these services themselves.In each area the detailed functions are conferred by statute on the names of those eligible are entered in a general Minister, including the regulation of services and register.It is estimated that about 23 per cent. of appointments.Furthermore, the Minister, through the entire population are catered for by this service. hisstaff,must ensure that the services provided General medical services are based on the dispensary by each local authority are adequate and efficient. districts of which there are nearly 600 in the country. In discharging his functions he is assisted by a number In each district there is at least one dispensary attended of advisory bodies, the most important of which is at fixed hours by a medical officer, who examines the National Health Council, representing medical and treats eligible persons free of charge.Those and auxiliary professions and other persons con- who cannot go to the dispensary are visited at home cerned with matters of health.The Council advises and the service of a consultant may be secured if the Minister on general questions affecting health. necessary.In some districtsnurses with general On matters specifically related to hospital facilities training have been appointed to assist the dispensary and the expenditure of monies from the Hospitals medical officers. Trust Fund, the Minister is advised by the Hospitals A comprehensive hospital service, free of charge, Commission.He may alsoset up from time to isavailable for communicable diseases,including time a special consultative council or committee on tuberculosis.Hospital services for other ailments any particular question.In recent years these councils are not provided for the entire population but are have advised the Minister on such matters as tubercu- limited to: losis, medical education and cancer.Special statutory (1)Manual andother workersearning£600 bodies which are in some respects subject to control (US $1680) a year or below; by the Minister deal with such subjects as the regis- tration of medical practitioners, dentists, nurses and (2)Other adults at the same salary level, and midwives, pharmacists and opticians.Other organi- (3)Persons whose means are derived wholly or zations established by the Minister deal with problems mainly from farming, where the farm is below a such as blood transfusion, rehabilitation, and mass certain valuation.It has been calculated that this radiography. covers about 87 per cent. of the farmers. 270 FIRST REPORT ON THE WORLD HEALTH SITUATION
Pupils of most elementary schools are entitled to (2) Cancer free treatment for defects discovered at school health Mortality has increased from 1.56 per 1000 popula- examinations. tion in 1954 to 1.58 in 1956.The increase is most It has been calculated that about 85 per cent. of marked in cancer of the respiratory organs; in 1954 the population are included in the categories entitled and 1956 deaths from this cause numbered 422 and to the above services.Hospital facilities are provided 470 respectively compared with 224 in 1950.The free to those entitled to general medical services and Cancer Association of Ireland was established in to others who may be accepted by the health authority. 1950 to assist in the diagnosis, prevention and treat- In other cases charges, generally not exceeding ten ment of cancer, and in 1954 the Association opened shillings (US $1.40) a day, may be made by the a modern cancer hospital.Other activities include health authority.Most health authorities provide the proposed establishment of a national cancer these services in their own hospitals, but in some register, and special arrangements for the training cases, particularly in the Dublin area, the services of physicians are under consideration. of voluntary hospitals are used to a great extent, and the cost is reimbursed by the local authority. (3) Tuberculosis Out -patient specialist services are provided for the The tuberculosis death rate has fallen consistently same groups of the population, and in some cases during the past ten years, and the 1956 rate -24 per moderate charges may be made by the health autho- 100 000-is the lowest yet recorded.This isstill rities. high, however, by comparison with the rate in some The following table gives particulars of hospitals other countries, and, moreover, the decline in mor- of various kinds in Ireland at the end of 1956: bidity has not kept pace with the decline in mortality. As adequate hospital accommodation is now available, Local authority Voluntary more attention can be paid to preventive measures.
Type of hospital number number number number (4) Poliomyelitis of beds of beds There was a high incidence of poliomyelitis in 1956 on account of an epidemic in the Cork area: 499 cases General and maternity 83 7 120 71 8 439 were reported as against 82 in 1954.Three main Tuberculosis . . . 34 5 300 14 1 760 centres have been established for the care of patients, Mental 21 19 734 13 925 equipped with modern appliances and with expe- Infectious diseases . . 26 1 500 -- Mental deficiency and riencedspecialist and nursingstaff.Seriouslyill epilepsy -- 12 2 250 patients are transported to these centres as quickly Health clinics. . . . 16 --- as possible.Vaccination is now being provided by Psychiatrictreatment local health authorities. clinics 75 - * - Rehabilitation centres -- 5 - (5) Mental illness The major problem as regards mental illnessis Data not available accommodation. Many of the district hospitals are seriously overcrowded mainly because of the increas- The birth rate has not varied much for a number ing number of elderly people admitted. of years.The last figure given is 21.0 for 1956. The death rate for the same year was 11.7, and the (6) Rehabilitation infant mortality rate was 36. A number of voluntary associations are active in The main public health problems of today are: this sphere; generally speaking, each of these associa- tions deals with a particular type of disablement. (1) Infant mortality Until recently the importance of the problem had Although the rate has declined during the period not been fully established, but the realization of its under review (from 38.0 to 36.0), it is still high.It is magnitude led to the creation, in 1955, of the National hoped that improvements effected in the services Organization for Rehabilitation, which was set up under the Health Act of 1953 and their extension by the Minister for Health and is making recommenda- to a wider range of the population will accelerate tions to him on how the problem may be met. the downward trend of thefigures. A perinatal Dental services are provided by local health autho- mortality survey isat present being conducted by rities for persons in the lower income group, for the Medical Research Council of Ireland. pupils of national schools in respect of defects discov- EUROPEAN REGION 271 ered at school health examinations, and for children hospital and specialist service.Each health authority under six years of age for dental defects discovered makes prior agreements with medical practitioners at child welfare clinics. and a capitation fee is paid.The doctor may call These services are free of charge except that in in a colleague for assistance at the expense of the the case of school- or pre -school children a charge local authority.Health authorities are required to may be made for the replacement of a dental appliance provide, in any town of 3000 or more inhabitants, if the need for replacement is due to negligence on child welfare clinics for the ascertainment of defects the part of the user.The dental services are provided and for the education of mothers in the care of their at dental centres operated by the local health autho- children.This service does not include treatment. rities.Dentists are employed on a whole -time or A health examination and treatment service is provided part -timebasis.The dentalserviceshave been forschoolchildren.Schoolmedicalofficersare improved in recent years by the appointment of employed by the health authorities and each child additional dentists, the establishment and equipment is examined at three periods during school life. of additional treatment centres, and other measures. The administration of the mental health service A dentist employed by the local authority visits the is in the hands of 18 mental hospital authorities, schools from time to time and examines the children's which are either county councils or joint bodies. teeth.Parents are encouraged to be present during The categories of person eligible for free treatment dental examinations and their consent is obtained are the same as those eligible for the general hospital for any necessary treatment.Health authorities have service, while persons not entitled to free treatment also been urged by the Department of Health to may be admitted to the mental hospitals on a paying give more consideration to the prevention of dental basis.The number of persons undergoing treatment defects, especially in the matter of popular instruc- for mental illness, including those in private institu- tion in dental hygiene. tions, was 21 242 at the end of 1954, 21 352 in 1955 A free medical care service for mothers, with and 21 720 in 1956.An out -patient clinic service is choice of doctor, is provided for women in the groups in operation, and at present there are 75 such clinics entitled to general hospital and specialist services. dealing especially with early cases.They are located This service includes attendance by a doctor before mainly in the county and district hospitals and in and after birth and, if necessary, at the birth; for suitable dispensary premises, and are conducted by the attendance of a midwife, and for any necessary the medical staff of the district mental hospitals.
ITALY
Italy consists of a peninsula projecting into the Mediterranean, provincial administration, which is carried out through the and of a number of islands, of which Sicily and Sardinia are the Provincial Councils and the Giunta. most important.It is bounded on land by France, Switzerland, The main occupations are agriculture, which employs 8 261 160; Austria and Yugoslavia, and its area is 301 191 square kilo- industry,employing6 289 733,and commerce, employing metres.The Alps form the northern boundary, and the 1 652 589.The country's mineral resources are in general poor, Apennines are the backbone of the peninsula itself.To the only sulphur and mercury providing any surplus for export. north stretches the wide and fertile valley of the Po; on the east Hydro -electric resources are widely exploited, and in 1956 the and west sides of the peninsula the mountains come down to the production of power from this source amounted to 31 307 million sea, except in some places, where they give way to coastal kWh. Large supplies of natural gas have recently been developed, plains of no great width.The climate is warm, and is tempered especially in northern Italy, and satisfactory results are being by the surrounding sea and cooled locally by the altitude and obtained in the search for mineral oil.The chief industries are the neighbouring mountains. textiles of many kinds, iron and steel, chemicals, motor vehicles, At the 1951 census, the population was 47 516 000, with a clothing and accessories (gloves, hats, handbags, etc.), ship- density of 154 per square kilometre.At the end of 1957, the building, and food -processing.If the index of industrial resident population was estimated at 49 895 000, and at the production is taken as 100 in 1938, by 1956 it had risen to 212. beginning of 1958 the population of the chief towns was estimated Furthermore, there are many different kinds of local craftsman- as follows: Rome, 1 880 629; Milan, 1 389 158; Naples, 1 118 880. ship, whose products are much sought after both inside and From the administrative point of view, the Republic of Italy outside the country. is divided into 92 provinces.Furthermore, four of the 20 regions Education is compulsory from 6 to 14 years of age, and there into which Italy falls geographically have recently obtained a are the following educational establishments: 14 865 kinder- measure of administrative autonomy; in these four regions, garten schools; 41 943 primary schools; 2361 secondary schools; a Government Commissioner directs the regional administration, 2458 professional schools; 570 technical institutes; 503 teacher - and the administrative organs are the Regional Council and the training schools; 987 higher institutions, and 26 universities Giunta (executive).In the provinces, the Prefect supervises the with a total of 191 faculties. 272 FIRST REPORT ON THE WORLD HEALTH SITUATION
The mercantile marine is now 4.5 million tons.The chief (4)Technical supervision of organizations and ports are Genoa, Naples, Trieste, Palermo, Venice, Leghorn and institutions (other than those mentioned above) which Savona.At the end of 1956, there were 21 824 kilometres of railways, of which 16 741 kilometres were government- owned, have health functions. and nearly 6000 kilometres have been electrified.There were also 176 984 kilometres of roads in 1956, of which 24 920 kilo- The Ministry has a Supreme Health Council, which metres were State highways.Civil aviation is well developed, acts in an advisory capacity for the national health and a unified airline runs many long- distance services.There are five international and 20 national airports, as well as 33 club administration.The chief technical body of the aerodromes. health administrationisthe Higher Instituteof Every commune has its own welfare body -the Ente com- Health, which is responsible for undertaking research munale d'Assistenza -which provides assistance to the needy on health subjects, carrying out analysis of drugs out of funds drawn partly from the assets of the provinces and communes and partly from special taxation. and food products, and control of sera, vaccines and biological products in general.The Institute Health has a number of departments, including: micro- During the unification of Italy, a movement which biology and virology; parasitology (and entomology spread from Piedmont between 1859 and 1870, the and insecticides);biology;biochemistry; pharma- health laws in force in Piedmont were extended to the cology; physics; and sanitary engineering. rest of the country.In 1888, a law was passed organiz- At the provincial level, the Ministry is represented ing the health services on a national basis, and the by the Offices of the Provincial Medical Officer and general structure of this legislation has been preserved of the Provincial Veterinarian, which are co- ordinated up to the present time, although many other laws have by the Prefect.The Provincial Medical Officer is an subsequently been added toit.After the Second official of the central administration and is assisted World War, the necessity for centralizing govern- in his many duties by one or more assistant provincial ment activities in the various branches of hygiene and medical officers, two or more medical social workers, public health into a single organization led to the and in some cases, one or more midwives, as well as creation of the High Commissariat for Hygiene and administrative clerks.He is also assisted by certain Public Health under the presidency of the Council specialists, in particular the inspector of the venereal of Ministers.The establishment of this High Com- disease control service, the provincial malariologist missariat was the first step in the creation of the (in the provinces where malaria was formerly endemic), Ministry of Public Health, of which the constitutive an ophthalmologist who helps to run the trachoma law was approved by the Senate in February 1957 control campaign, and others.There is also a Pro- and by the Chamber of Deputies in March 1958, and vincial Health Council, under the chairmanship of came into force on 14 August 1958. the Prefect, which acts as an advisory body to the The duties formerly carried out by the High Com- Provincial Health Office. missariat for Hygiene and Public Health, and the In the communes, the mayor is the chief health health functions of other branches of the Government, authority, and is assisted by the physician in charge have been transferred to the Ministry of Health, of the communal health department, who is appoin- which is made up of the following departments: ted by the mayor on a competitive basis.In communes administrative matters and personnel; public health with more than 20 000 inhabitants, the health officer servicesand hospitals;socialmedicine; pharma- works full -time, but in smaller communes a local ceuticalservices,andveterinaryservices.Inter- practising physician with an adequate public health national and cultural affairs are the responsibility of a background may be appointed to take charge of special office, directly under the Minister.The func- public health work on a part -time basis.In some tions of the Ministry of Health have been fixed by provinces, a number of small communes may join law as follows: together to form inter -communal unions, and in such cases an inter- communal health officer is appointed (1)Responsibility for the health services assigned to be responsible for the health services of the com- by law to the State civil administrations; munes concerned.The Communal Health Depart- (2)Supervision and co- ordination of the health ment of the large towns usually provides the following services carried out by independent State administra- main services: preventive care, social medicine, en- tions and public institutions, including, if necessary, vironmental sanitation, school health, medical care, the adaptation of the structure and effectiveness of veterinary medicine, and general health administrative these services to meet the needs of the public health; services.In the smaller communes and in the inter- (3) The issuance of instructionstoall public communal unions, more or less the same services are administrations which have health functions; provided but on a more limited scale. EUROPEAN REGION 273
The communal medical service is based essentially institutes.There were also 7200 registered veteri- on the condotta medica (one of the oldest of Italy's narians, 200 being employed by the health authorities, health institutions), a communal dispensary íznder 2000 attached to the communal veterinary services and the direction of a physician appointed by the com- about 1000 practising in the animal hygiene institutes munal authorities and responsible for care of the and public slaughter- houses. sick.There are more than 9000 of these dispensaries The public hospitals are run to a large extent by in the country, so that the services of a physician are local voluntary organizations,subject to adminis- available even in the smallest and most inaccessible trative control by the Prefecture and the Ministry mountain villages.In the large urban centres, these of the Interior, and to technical supervision by the dispensaries are attached to the local health depart- appropriate Provincial Health Office.In 1956 the ments.The public healthvisitorsof the health total number of hospital beds was 362 053, with the departments carry out home visiting and in some heaviest distribution in the north; an effort is being towns in the north there is a trend towards creating made to increase their number in the south.Of the special" domestichelp "servicesinthehealth total number of beds, 78 964 were in psychiatric department. hospitals. Although the law establishing the Ministry put all The Central Statistical Institute is responsible for government public health activities in the hands of one collecting, analysing and publishing health statistics. body, other Ministries are concerned with health A National Health Statistics Committee was set up matters within the sphere of their own jurisdiction; in 1951 to provide liaison between the High Com- in particular, occupational health and social welfare missariat of Hygiene and Public Health and the remain the responsibility of the Ministry of Labour Central Statistical Institute.This Committee under- and Social Welfare.Furthermore,certain health took a survey of hospital morbidity in 1954 and, activities are entrusted to semi -official institutions more recently, a random sample survey of the incidence which are supervised by the national health adminis- of various diseases and disabilities among 75 000 tration, and there are also some national associations families. which are engaged in health work and preventive and In 1956, the birth rate was 17.7, and the general social medicine. mortality rate was 10.1.The infant mortality rate Since the First World War, a number of insurance was 53.0 in 1954, 50.9 in 1955 and 48.4 in 1956, and systems have been set up under the authority of the the maternal mortality rate in 1955 was 1.3. Ministry of Labour with funds from compulsory The principal causes of death in 1954 and 1955 contributions by workers and employers; the families were cardiovasculardiseases,malignant tumours, of insured persons are also entitled to benefits.In- accidents and pneumonia. surance against tuberculosis, invalidity, old age and Thespecificmortalityof acute communicable unemployment is administered by the National Social diseases has declined from 368 deaths per 100 000 Welfare Institute, which covers more than 25 million inhabitants in 1900 to 38 in 1954.Nevertheless, workers.Most of the former mutual aid societies salmonellosis morbidity isstill high and calls for have amalgamated with the National Sickness In- appropriate measures.Endemic helminthic foci - suranceInstitute, which covers some 22 million particularlyofankylostomiasis - stillexist,and workers in commerce and industry, including pen- there is a need for intensification of case -finding and sioners.The National Institute for Insurance against treatment of patients and carriers of this group of Occupational Accidents and Diseases, and the Nation- diseases.The reported cases of poliomyelitis num- al Institute for the Prevention of Accidents administer bered 3404 in 1954, 2685 in 1955, and 3485 in 1956 the compulsory insurance, which covers workers in - mainly among children in the 0 -5 years age -group. industry, the building trade, agriculture and transport. In 1956 a system of voluntary vaccination was intro- The former insures approximately four million workers duced, using Salk vaccine manufactured inItaly. a year, on the basis of a theoretical unit of work of In 1955 there was an epidemic of meningo -encephalitis eight hours a day, three hundred days a year. in the Marches, probably due to a Coxsackie type A At the end of 1956 there were 72 000 physicians virus. (including dentists) practising inItaly.Of these, The successful malaria eradication campaign has 15 400 were in the public health services at various resulted in a decrease in the number of cases of malaria levels and 20 650 were working in hospitals.Four from 210 828 in 1947 to 451 in 1951 and 43 in 1952. thousand physicianswereattachedtoinsurance Since 1953, no primary cases of local origin have been companies and sickness funds on a full -time basis found.Control measures arestill carried out in and about 40 000 were contracted to the insurance certain areas to ensure that the disease does not 274 FIRST REPORT ON THE WORLD HEALTH SITUATION
spread again, and a number of studies on the subject run a large number of institutions for pregnant of anopheline resistance to insecticides and on the use women, orphans and abandoned children. of new substances have been or are being carried out. In order to develop the school health service, In 1950 -51the tuberculosis mortality rate was the health authorities set up, between 1954 and 1956, just over half the lowest rate registered before the war some 180 clinics staffed by school doctors and health (1938 - 79.7; 1951 - 42.2) and since the introduction visitors, and 81 school dental clinics.Legislation is of isoniazid therapy the mortality has dropped even being prepared to provide for a national school further, to 27.7 in 1952 and 22.7 in 1955.The medical service, which will be under the Ministry of National Social Welfare Institute and the provincial Health with provincial branches attached tothe anti -tuberculosis associations are responsible for the Provincial Health Offices, and services for the com- treatment and prevention of tuberculosisinthe munes provided by the communal health departments. country.In 1956 there were 565 tuberculosis control The health authorities organize and co- ordinate dispensaries, 57 sanatoria, with 77 499 beds, and 11 882 health education activities through the Provincial beds inpreventoria.Thereisalso an extensive Health Offices and encourage the production of audio- network of x -ray services which took 1 700 000 films visual media for purposes of health education.In in 1955.These services are not engaged exclusively the province of Perugia they have sponsored a prac- in tuberculosis case -finding; they also detect cardio- tical health education demonstration centre as a vascular diseases, lung tumours and other diseases of pilot scheme.In many provinces there are com- the respiratory organs. mittees for health education of the public.In the In 1956 there were 413 cases of leprosy, including communes the communal health departments and 221 hospital in- patients. the communal medicalofficerscarry out health There are 220 venereal disease control dispensaries, education work in the community and in the schools. which record about 130 000 new cases each year. A National Health Education Committee was set up The estimated number of trachoma cases varies in 1955 to stimulate health education work among from 250 000 to 350 000, and in 26 provinces pro- the various voluntary associations concerned with vincial anti -trachoma organizations have been est- public health activities, particularly tuberculosis con- ablished with public and school clinics, specialized trol, maternal and child health and cancer control. hospital services and a health visitor service attached Refresher courses are organized yearly by the health to each of them.In 1955, 20 500 children were seen administration for public health workers. in the school trachoma clinics and 17 000 adults The responsibility for mental health services rests were treated in the general consultation services. with the provincial administration.Between 55 000 Veterinary services are part of the health administra- and 60 000 mental patients have been admitted to tion, and important measures are being taken in the hospital annually during recent years. A number of control of zoonoses, particularly canine rabies, hae- psychiatric dispensaries have recently been set up, matic anthrax and glanders. A recent survey of and the hospitals and dispensaries now have the bovine tuberculosis showed that about 11 per cent. of services of social workers at their disposal.For livestock are infected in the northern provinces, and a mentally retarded children and those suffering from programme for its control has been drawn up.With behaviour disorders, special schools or classes have regard to brucellosis, the results of bacteriological been established with psychiatric services attached investigations carried out in 1955 -56 revealed 1.38 per to them. A number of organizations have recently cent. positive in central Italy and 16 -50 per cent. posi- set up child guidance clinics, and some rehabilitation tive in northern Italy.Appropriate measures are centres for juvenile delinquents have been opened. being taken to control the disease. Medical inspectors of labour, working under the Maternal and child health work is directed and co- Ministry of Labour and Social Welfare, are responsible ordinated by the National Maternal and Child Health for safeguarding the health of workers and taking Service, under the supervision of the Ministry of the necessary steps to prevent occupational diseases, Health.This service is organized on a territorial as laid down by law.Many large industries have basis,with provincial federations and communal well- equipped medical services in which there is a committees, the latter under the chairmanship of the growing tendency to deal with the mental health and mayor.In 1956 there were 463 maternity homes, the problems of family life of the workers. 5285 paediatric clinics, 2588 paediatric clinics with With regard to chronic and degenerative diseases, obstetrical consultations, 239 clinics for skin diseases increasing attention is being given to cancer control. and syphilis, 829 canteens for pregnant women, and Apart from three cancer institutes in Rome, Milan 395 nurseries.The public welfare authorities also and Naples, there are cancer control centres through- EUROPEAN REGION 275 out Italy; their number increased from 36 to 62 and re- education of persons recovering from polio- between 1953 and 1956, and 18 others are about to myelitis, as well as nine for the treatment of recent be opened.For the control of rheumatism and cases, 17 for the treatment of long- standing cases heart diseases there were 29 rheumatological and and eight mixed centres; in 1955 and 1956, five new cardiological centres in the country in 1956, mainly centres were set up.For the rehabilitation of spastic for the benefit of pre -school and schoolchildren, and cases 13 centres were opened between 1954 and 1956, 18 others are being built. and four more are being built. It is estimated that some 300 000 persons are at As part of the nutrition programme, the health present suffering from diabetes in Italy, and many authorities have introduced the subject of nutrition centres for the control of this disease have been est- and dietetics into the training curricula of physicians, ablished in recent years through the joint efforts of health visitors, nurses and other health personnel. the municipal health departments in large towns, the Furthermore, with a view to gaining knowledge of university clinics and certain welfare institutions. the effects of food habits on the health of the people, Rehabilitation services have been organized, parti- the National Institute of Nutrition (which is attached cularly in traumatology and orthopaedics, but during tothe National Research Council) hasrecently the last few years they have been extended to other carried out in one commune the first of a series of fields,suchastuberculosis.Thirty -fourspecial nutrition surveys on the dietary habits and nutritional centres have been established for the rehabilitation status of the Italian population.
LUXEMBOURG
The Grand Duchy of Luxembourg, in Western Europe, has first modern administrative measures, taken between an area of 2586 square kilometres, and is bounded by Germany, 1900 and 1906, put into practice the principles of Belgium and France.Much of the country is hilly and wooded but there is reasonably good agricultural land and important bacteriology.In1945, following the example of iron ore deposits in the south. many other countries, a separate Ministry of Public The population at the 1947 census was 290 992 with a density Health was created, and from then onwards complete of 118 per square kilometre; more recent estimates of population reorganization was undertaken.The functions of this are as follows: 304963 in 1954, 307 700 in 1955, and 311 033 Ministry have been gradually widened to include the in 1956.The capital, Luxembourg, has a population of 62 000. The language of the country is Letzeburgesch, with French as various fields of general and social health.General the official language, and the people also speak German. health services are dealt with solely by the Govern- The general educational level is high. A rough estimate of ment, while much of the social health work is carried the main occupations includes the employment of 35 000 people out by semi -official and private organizations, which in agriculture, 54 000 in mining and industry, and 25 000 in commerce. are placed under the control of the Ministry of Public The Grand Duchy of Luxembourg has a Chamber of Deputies Health. consisting of 52 members elected by universal adult suffrage for The Ministry of Public Health is assisted by a six years.There is also a Council of State of 15 members chosen medical body, which acts in an advisory and disciplin- for life by the Sovereign; it advises on proposed legislation and is on other questions referred to it by the Government, and gives ary capacity.The Director of Public Health administrative decisions. Among the members of the Cabinet responsiblefortheadministrative andtechnical are Ministers of Education, Public Health, and Labour and direction of the health services.Medical inspectors Social Services. work on a regional basis as far as general health Economically speaking the most important industry is iron services are concerned, but they are all specialized in and steel, the foundries being in the south of the country. There are also crops of oats, potatoes, and wheat, and yields some branch, such as paediatrics, hospitals, etc. of meat, butter and wine.Luxembourg belongs to a Customs The main health problems at the present time are: Union (Benelux) with Belgium and the Netherlands.Production reorganization of the school medical services; control is mainly in the hands of private enterprise. of tuberculosis; control of medicaments; moderniza- Education is compulsory for all children between the ages of tion of legislation on foodstuffs, water, and air pollu- 6 and 13. In 1952, 78 000 persons were covered for sickness and mater- tion; medical and social assistance to the handicapped; nity benefits, and 102 000 for occupational accidents. and the organization of mental health services. All statistical matters are dealt with by the Central Health Statistical Office, with the exception of communicable At the beginning of the century a " sanitary ser- disease statistics, which are the concern of the health vice " was attached to one of the ministries.The services. A law is being drafted to provide that 276 FIRST REPORT ON THE WORLD HEALTH SITUATION compulsory declaration of causes of death shall be All dental hygiene is carried out under private under the jurisdiction of the public health services. initiative, although large towns have organized school The following rates were recorded for the period dental services. 1954 -56: Pre -natal examinations are recommended for preg-
1954 1955 1956 nant mothers.School health is partly the respon- Birth rate 16.3 16.1 16.3 sibility of the municipal authorities; the State organizes Death rate 11.4 11.4 12.5 school medical services in the intermediate schools. Infant mortality rate . . . . 43.8 38.9 36.7 The problem of communicable disease control is dealt with by three medical inspectors, three sanita- The following medical facilities exist: a government rians and three public health nurses.Vaccination public health laboratory; 3500 hospital beds, including against smallpox has been compulsory since 1916, and a government maternity clinic with 70 beds and free vaccination against diphtheria, poliomyelitis and various smaller municipal or private maternity clinics; tuberculosis has been organized by the Government. two sanatoria for tuberculosis patients, with 200 beds, A plan for a compulsory industrial medical service and a psychiatric institution with an external social is under consideration. A number of industries have service. voluntarily appointed industrial medical officers who The distribution of medical personnel is as follows : work under the supervision of the public health (a) 16 administrative medical officers -four in the medical inspectors. central administration, three in the public health A government institution with 400 beds is available laboratory, four in sanatoria, four in the mental home for the chronic sick.There is a tendency to decen- and one in the maternity clinic; (b) 250 physicians; tralize the medical care of chronic tuberculosis patients (c) 42 paediatricians; (d) 116 dentists; (e) 150 phar- by creating small sections in the hospitals; there are macists; (f) 130 home -visiting and hospital nurses; at present three such sections with 25 beds. (g) auxiliary personnel -69 midwives, 742 nursing For old people there are six government homes aides, 34 laboratory assistants and 56 physiothe- with 300 beds, one foundation with 170 beds and eight rapists. private institutions with 250 beds. There is no university medical course, but there are About 98 per cent. of the population are served by two schools for auxiliary medical personnel which a piped water system.Programmes for the prevention take in 50 -60 students each year. of water pollution are being undertaken, and studies The organization of a special service for health are being made for the control of air pollution.An education of the public is under consideration.At urban housing service has recently been established, the present time health education is carried out by and the approval of the public health service must be means of the press, radio, and special teacher training sought for the construction of public and municipal courses. buildings.
MONACO
Monaco is situated on the north -west coast of the Mediter- control of establishments providing curative and ranean, with land frontiers joining France at every point. preventive services, school health, industrial health, The whole available ground is built over, and the only cultivation is that of public and private gardens.The area is 1.5 square blood transfusions, and the control of communicable kilometres, and the population at the 1951 census was 20 202. diseases (including immunizations). The annual rate of increase in 1951 was 1.01 per cent. Medical care in the home is provided by private There is an excellent small harbour, and the main railway line practitioners and nurses and by three doctors of the from Marseilles to Italy, through Cannes and Nice, passes government health service.There isone hospital though the Principality. The educational system is closely modelled on that of France. with approximately 300 beds, and clinics for tuber- culosisand venerealdiseases.Regularspecialist Health consultations are provided for mothers and children, A health service was founded in Monaco in 1911, and a medical inspection service for schoolchildren and since 1955 it has been directed by a Commissioner and athletesisconducted by a full -time doctor. of Public Health.The services provided include the The aged are cared for in the hospital and in a special controlofprofessionalpractice,supervisionof home maintained by the Municipality in an adjoining pharmacies, pharmaceutical products and laboratories, commune. EUROPEAN REGION 277
The medical and health personnel in Monaco consist In 1956 the reported cases of certain communicable of 40 doctors, 14 dental surgeons, 14 pharmacists, diseases were :diphtheria, 1; measles, 13; whooping - two midwives, 24 nurses and six social workers. cough, 61. No cases of poliomyelitis occurred during A midwifery school with a capacity for 20 students the period under review. provides a three -year training course, and nursing The public health laboratory carries out regular con- aides are trained in the hospital. trol of milk and water.The entire population is pro- Tuberculosis and cancer are the two problems vided with a water -supply system, and the annual water which are receiving special attention. consumption per person in 1956 was 590 cubic metres.
MOROCCO
Morocco lies at the north -west corner of the African conti- In addition to inspectorate services, the Ministry nent between 38° and 63° north and 1° and 12° west.It is of Healthatpresent comprisesthree traversed from the Atlantic coast in the south -west to the divisions : Algerian frontier by the five ranges of the Atlas mountains. health,preventivemedicineandadministration. Between these ranges are well- watered and fertile plains.The Directly under the Minister there is a Secretary - southern slopes are exposed to the dry winds from the desert General.The Central Pharmaceutical Service, the and are generally arid.The climate is pleasant and healthy, Laboratory Service (which includes the Institute of especially on the Atlantic coast, which is sheltered from the hot winds of the Sahara by the Atlas.The Mediterranean coast Hygiene of Morocco), the National Blood Transfu- is drier and less temperate and the plains of the interior are sion Service and the Professional Education Service intensely hot in summer.The area is some 410 805 square are available to all the technical divisions of the kilometres. Ministry.The Health Division isresponsible for The population of Morocco is about 9 176 102 according supervision of hospitals and medical care services, to the last census, taken between 1950 and 1952.The principal townsareCasablanca(682 388inhabitants);Marrakesh and attached to it is a national health council.The (245 312); Fez (179 372); Rabat (156 209); and Meknes (140 380). Division of Preventive Medicine is responsible for In 1956, over two million people were employed in agriculture, urban and rural health services; occupational health; 250 000 in manufacturing and 150 000 in commerce. sanitary control of frontiers; control of communicable The economy is mainly agricultural.Large irrigation works have begun; a dam at Bin el Ouidane provides for the irrigation diseases and cancer; psychiatry; maternal and child of 1390 square kilometres of semi -desert, and further works health; health education and school health.The are in progress.Morocco has important deposits of iron ore, AdministrativeDivisionincludesallthegeneral manganese, coal, cobalt, lead and zinc, which are being increas- administrative services of the Ministry. A welfare ingly exploited. service is specially responsible for all forms of social Illiteracy isfairly widespread among the population, but there are many Koranic schools, which give an elementary assistance, and for seeing that appropriate assistance education, and a few higher schools attached to the mosques. is given, in case of need, to children, old people and The best known of these is the Kairoween University at Fez, invalids. which has a high reputation throughout Islam.A modern At the provincial and prefectural levels there is educational system is being developed. At the end of 1957 there were about 1800 kilometres of a chief medical officer representing the Ministry of railways, of which 760 kilometres have been electrified.The Health and in charge of the health work throughout main lines run between Casablanca and the Algerian border the territory under his jurisdiction.In the social and are part of a continuous line to Tunis.In 1957 there were field, the chief medical officer is advised by the pro- over 12 600 kilometres of motor roads, of which 7300 kilometres vincial or prefectural chief social worker. were main roads and 5300 kilometres were secondary roads. Regular air services are provided by a national air company At the end of 1956, 4362 personnel (2672 Europeans and seven foreign companies. and 1690 Moroccans) were employed by the Ministry of Health, including 659 physicians, pharmacists and Health dentists; 150 social workers; 2849 midwives, nurses and other auxiliary technical staff, and 704 admini- In 1913 a health service was established in Morocco, strative personnel. combining the military health service and the civilian A Professional Education Service was formed in Health and Public WelfareService.In1926it the Ministry in 1956 with the object of adapting became the Directorate of Public Health and Hygiene, facilitiesfor the training of male nurses, female and was later transformed into the Ministry of Health, nurses and midwives to the needs of the country and, under the Constitution of the first Moroccan Govern- in particular, of organizing a publicity campaign in ment, adopted on 7 December 1955. order to attract to the professional training schools 278 FIRST REPORT ON THE WORLD HEALTH SITUATION more young men and women with a constantly cases.During the " family " campaign, 46 502 cases higher level of general education.In the seven were found and 37 098 patients and contacts were schools for male and female nurses and midwives treated.During the " community " campaign, 105 281 in the year 1956 -57, 398 students were under training. serological tests were made and 12 273 cases were The building of fiveschools of nursing (female) treated. and midwifery was started in 1957. Maternal and child health is an integral part of The following institutions were providing medical the general. policy of public health, which aims at care in 1956:13 general hospitals;124 regional, health education of the public in every way possible. municipal and rural hospitals and nursing posts; 27 Originally the Ministry of Health laid much stress specialized institutions for tuberculosis, ophthalmology on health education of the female population; the and neuropsychiatry; 312 rural dispensaries (con- emphasis has now shifted to awakening a greater sulting rooms); and 125 health centres, dispensaries, interest among all sections of the population. A mobile health units and medico -social centres. plan has been drawn up to this end, which includes In tuberculosis control, emphasis has been placed the building of a certain number of rural and urban on case -finding.For treatment of tuberculosis pa- dispensaries, the latter to serve specified districts of tients 2410 beds are available, of which 1480 are towns. in hospitals, 930 in sanatoria, and 550 in preventoria. Maternal and child health activities are carried Since 1949, a mass BCG vaccination campaign has out in maternal and child health centres, which consist been in progress with vaccine supplied by the Pasteur of a day nursery, an infant clinic and facilities for Institute of Casablanca. training mothers.The activitiesof the maternal The campaign against eye diseases has been pro- and child health centres in 1954 -56 can be tabulated ceeding in Morocco during the period under review, as follows: and the work has been carried out largely through 1954 1955 1956 the local health services and field campaigns.Six Pre -natal consultations . . . 50059 ophthalmological hospitals provide a total of 640 beds, 61976 121442 Infant consultations . . . . 320480 442663 651148 and, in addition, there are 22 out -patient clinics Dietetic and infant care de- distributed in the various towns.Mobile ophthal- monstrations 172788 177986 204317 mological teams supplement the work of the central units.In 1955 a total of 2 521 508 ophthalmological In 1955 a sampling survey of levels of living was consultations were given by the variousservices. carried out among the population. This work, in addition to the effective control of Owing to the rapid industrialization of the country, seasonal epidemics of conjunctivitis, has reduced the the health problems of workers have become urgent incidence of trachoma by enabling the people to and the Ministry of Health has recently taken mea- treatthemselves.Thetotal number of persons sures to establish occupational health services and treated for trachoma and conjunctivitis in the three - has promulgated the necessary legislation. year period was: 260 000 in 1954; 412 049 in 1955 In the field of mental health, the Ministry of Health and 1 320 283 in 1956.The total number of school- has set up a special mental health section and is under- children treated for trachoma during the three years taking thereorganization and expansion of the was 126 499. existing central psychiatric hospital and the develop- Under the venereal disease control programme, ment of regional psychiatric services in the principal 346 782 serological tests were made and 76 828 patients towns.The most widespread form of drug addiction were treated in 1954 and 1955.In 1956, the control in Morocco is addiction to hashish; a thorough study methods were modified to operate on a family and has been made of this problem, and a control pro- community basis, including the treatment of detected gramme has been started.
NETHERLANDS
The kingdom of the Netherlands is a maritime country of delta.The land area is 34 830 square kilometres and it is being Western Europe on the North Sea, lying between 51° and 54° steadily increased by reclamation from the Zuider Zee. north and 3° and 7° east.It is bounded on land by Germany The population at the 1947 census was 9 625 499 and was in the east and Belgium in the south.The country generally estimated in 1955 at 10 751 000.Approximately 54.6 per cent. is flat and low -lying -below sea level in places -and is inter- of the people are urban, and the largest city, Amsterdam, has sected by many canals and connecting rivers.The principal a population of 803 847.The country is divided into 11 pro- rivers are the Rhine, the Maas and the Yssel, with the Scheldt vinces and 1014 municipalities. EUROPEAN REGION 279
The ministries in the Cabinet include Social Affairs and Public The responsibility for national public health rests Health; Education, Arts and Sciences; Agriculture, Fisheries with the Minister of Social Affairs and Public Health, and Food; and Social Work. As a result of intensive cultivation there is a large yield of who is assisted by a Director -General with an adminis- agricultural products of many kinds.On the industrial side, trative staff of well over 50 civil servants and a number there are 12 coal mines in the province of Limburg, several oil of advisory boards, such as the Central Council refineries, and a substantial production of crude petroleum. for Public Health Affairs, the National Health Council, The mainindustriesarefoodstuffs,metals,textiles,and chemicals; fishing is also a large industry on the North Sea. the Sickness Fund Council, the Nutrition Council The Netherlands are joined with Belgium and Luxembourg in and the Rehabilitation Council.On the technical the Benelux customs union. side four Chief Medical Officers, in charge of State Primary and secondary education are given in both denomina- inspectorates directly responsible to the Minister of tional and State schools: the former are eligible for State assist- Social Affairs and Public Health, deal respectively ance on equal terms with the latter.Attendance at primary school is compulsory.Secondary schools for children from with public health, mental health, pharmaceutical lower income -group families are numerous, well equipped and health care and veterinary healthcare. Certain well attended.There is practically no illiteracy.The prin- healthactivitiesare undertaken by bodiesother cipaluniversitiesareat Amsterdam, Groningen, Leyden, than thehealth authorities,suchas :(a)social Nijmegen (Roman Catholic) and Utrecht.There are technical insurance under the Sickness Insurance Act and the universities at Delft and Eindhoven (polytechnics), Rotterdam and Tilburg (economics), and Wageningen (agricultural science). Industrial Accidents Insurance Act;(b) inspection The principal ports are Rotterdam and Amsterdam.There of factories and workshops and industrial health are 7000 kilometres of navigable inland waterways, of which services attached to large industries; (c) the hygiene 1616 kilometres can take shipping of over 1000 tons.The total of housing (under the Ministry of Housing);(d) length of railways in 1952 was 3210 kilometres, of which 1283 kilometres were electrified.In January 1953 there were questions closely related to health, such as social 4000 kilometres of main roads, 4235 kilometres of secondary care of the blind, the deaf, the handicapped and roads, and 5500 kilometres of third -class roads. A national the care of old people (under the Ministry of Social airline maintains regular services to all parts of the world. Work). At the end of 1956, eight million people were covered by insurance schemes for medical care; five million for old -age, The provincial public health authorities are mainly survivors' and invalidity pensions, and two million for accidents concerned with drawing up regulations and granting of employment. subsidies, and have few executive powers.The 1956 Health Act, however, provides for the establishment Health of provincial councils of health, which enables the provinces to participate in health care. Modern health service in the Netherlands may be The municipal authorities are much more closely said to have begun in 1865, when an act was passed connected with health care,since they have far - providing for State supervision of public health.At reaching legislative powers and a good deal of executive the same time various voluntary agencies, destined responsibility, such as for carrying out the various to take an important share in public health work, acts (including communicable disease control, vacci- began to make theirappearance.At firstthey nation, and so forth).These authorities may keep specialized in home nursing, but gradually they spread public health care largely in their own hands, and this over many other public health activities - maternal is done in a few of the larger municipalities where and child health, preventive services and the fight the voluntary associations have not developed to the against tuberculosis.Indeed an underlying principle same extent as elsewhere.However, since the end of public health care in the Netherlands is that the of the 19th century, the voluntary bodies known as services are actually carried out by voluntary agencies the Cross Associations have taken a leading part in while the central Government restricts its activities general preventive work, and the organization of tosupervision,regulation and adjustment.This health centres and advisory bureaux - especially in principle means in practice that the public themselves the small municipalities - rests with them.In the are very deeply concerned in everyday health care earlier stages emphasis was placed on health centres through their membership of voluntary agencies. for infants and young children and for the care of The central Government helps these agencies to carry the tuberculous.Nowadays there are also services on their work, mainly by subsidies under certain for mental health, the care of the aged, as well as for conditions.This relationship between private initia- rheumatism and cancer sufferers.In the smaller tive and theauthorities works most successfully municipalities the local authorities often work in when the subsidies are large enough to develop the close co- operation with the local branches of the service while leavingtheenterpriseof voluntary Cross Associations in such services as school health bodies unhampered. and dental health. 280 FIRST REPORT ON THE WORLD HEALTH SITUATION
Certain services - food control, for example - is represented by about 12 000 qualified nurses and are frequently undertaken jointly by a group of local 13 000 student nurses. authorities. Medical care in the home is provided by family The collection of vitalstatistics dates from the doctors either in private practice or in sickness fund 17th century or even earlier, but systematic administra- practice.Doctors are assisted in home care by dis- tion began in Napoleonic times (compulsory registra- trict nurses and physiotherapists as required.Spe- tion of births, deaths and marriages dates from 1811). cialist consultation may be carried out either in the Local censuses have been taken since 1417, but the home or in out -patient departments.At the end of first regular census of the country as a whole was 1956 there were 4527 family doctors, 2891 specialists, taken in 1829.Under the Chief Medical Officer, 910 midwives and 2258 physiotherapists in practice. the Central Bureau of Statistics compiles all the data Further, there were about 2700 local district nurses, on health and vital statistics from medical certificates, 200 district nurses and 3500 maternity aides, as well and the system of registration is combined with the as about 1000 private nurses under private employ- regular ten -year census.The vital statistics for 1954 ment bureaux. were: birth rate, 21.6; death rate, 7.5; infant mortality For the various branches of health care there are rate, 21.1. dispensaries which to a small extent form part of The Chief Medical Officer of Mental Health collects health centres.These dispensaries are advisory and data on patients in asylums and similar institutions, do not as a rule provide treatment.There are 44 for including mentaldefectives. A large number of pre -natal care, 2095 for babies and 986 for young otherservicesinthe Netherlandsalsoregularly children.There are alsospecial dispensariesfor collect data on their own subjects, including tuber- dealing with prevailing diseases such as tuberculosis, culosis, cancer, the provision of maternity care, school rheumatism and cancer. A number of consultation medical inspection, and other matters. centres for marriage guidance have been established. Private initiative has also played an important After -care is mainly given by family doctors and part in the provision of medical care.Up to 1940 district nurses, but an organized rehabilitation service the general sickness funds (also dating from the 19th is in the course of development.Provincial rehabilita- century) provided a voluntary sickness insurance tion services are being set up, and 84 units are now which covered about 50 per cent. of the population. in operation.There are three special rehabilitation When in 1941 a statutory regulation providing for hospitals, but facilities for rehabilitation are being compulsory insurance was introduced, the earlier developed in several other hospitals and sanatoria. organization was used as its basis.All persons in In addition there are about 150 sheltered workshops paid employment earning less than 6900 guilders run jointly by the health authorities and private (US $1816)per annum are,withtheirfamilies, initiative. compulsorily insured.They are entitled to medical The total number of dentists in the country is 2400, aid from a general practitioner, a specialist or a mid- of whom about 1700 co- operate with sickness funds. wife,ten weeks' hospital nursing, pharmaceutical Dental care of insured persons is given mainly at the aid and assistance towards the cost of nursing in a dentists' private consulting rooms; only in six towns sanatorium and towardsdentaltreatment.For is it given in polyclinics.Patients who have neglected voluntary sickness insurance the income limit has dental care must contribute to the cost of treatment; now also been fixed at 6900 guilders (US $1816) per free treatment is given to dentally fit patients on annum. About 75 per cent. of the population are now condition that they have their teeth examined every covered by sickness insurance, either compulsory (in six months.There isan extensive school dental which case employers and workers both contribute 2.1 service covering about 50 per cent. of primary school- per cent. of the salary), or voluntary.By this means children (approximately 600 000), and there are a the sickness funds have finances at their disposal; number of experimental centres providing dental they pay for almost all curative services and are care for children between 3 and 6 years.As the even able to share in the cost of preventive health dentists available are hardly able to meet the demand, care. a plan is under consideration to direct treatment In the Netherlands there are 221 general hospitals, covered by the sickness fund mainly to the child and 42 specialist institutions and 43 sanatoria.Seven to provide more limited care for other age -groups. of these are State hospitals and 41 are municipal At present 60 per cent. of all confinements are atten- establishments; the others are private institutions. ded by physicians and 40 per cent. by midwives; both The medical care in these hospitals is as a rule provided give pre -natal care to their own patients, and may send by a specialiststaff.Nursing aid for the people a woman to a pre -natal clinic run by the Cross Associa- EUROPEAN REGION 281
tions or by the local health services (as is the case in of full -time regional officers who are qualified psy- the large towns) for a single complete medical and chiatrists.The voluntary organizations, which are obstetrical examination free of charge at the beginning grouped together into the National Federation for of pregnancy.These clinics are subsidized by the Mental Health, play an important part in the mental Government and each has a team consisting of a health services and co- operate closely with the central, gynaecologist, a tuberculosis doctor, a dietitian and a provincial andlocalgovernmentauthorities.In laboratory worker.About 25 per cent. of the con- most cases public funds are made available to them finements take place in hospitals or maternity clinics. if the authorities, advised by the Chief Medical Confinements at home are assisted by family doctors Officer of Mental Health, are convinced that the work or midwives with specialist help if required.Of the is of importance and will be carried out to required 233 877 confinements in 1956, 95 648 were attended standards.The mental hospitals and institutions by midwives. for the mentally deficient are capable of accom- Some 60 000 families are assisted each year by modating about33 000patients(27 000mental maternity aides, of whom as already mentioned there patients and 6000 mentally deficient cases), and the are 3500.They receive15 months' training and procedure for admission is similar to that of a general work under the supervision of a " matron teacher " hospital.Apart from the mental hospitals,there who is a qualified nurse and head of the maternity are growing numbers of psychiatric patients in general centre from which the aides are sent out to the families; hospitals, and the university clinics have also psy- their work comprises care of the mother and child chiatric in- patient and out -patient departments. There as well as housekeeping.There are alsodistrict are, furthermore, polyclinic centres and - in some maternity aides who only attend to mother and large towns - psychotherapeutic centres.Prevention child once or twice a day. and follow -up are carried out by the socio- psychiatric Vaccination against smallpox in the child's first services; psychiatrists and social workers advise the year is strongly recommended, as well as immunization family doctor and the families and maintain contact againstdiphtheria,whooping- cough,tetanusand with the mental hospitals for the admission and poliomyelitis.For organized vaccinations the serum discharge of patients. A centre for forensic psy- is provided free of charge by the State.Some of the chiatry was established at Utrecht a few years ago. large towns have a separate epidemiological service, There are 36 occupational health services in single but a regional or national service does not exist. factories or industrial concerns, employing a total of The school health service consists of 144 units 122physicians;21occupationalhealthservices (with a staff of 320 school medical officers and about covering more than one factory or industrial under- 150 nurses) and covers1 500 000 schoolchildren. taking, employing 46 physicians; and seven municipal The school medical officers collaborate with the family health services each with an occupational health doctors and the teaching staff and carry out regular branch, employing15physicians.Theseservices examinations of all children during their school life. employ altogether 492 250 workers. During the past few years, nursery schools and second- The primary task of the Cross Associations in the ary schools have been included to an increasing extent care of the chronic sick is bedside nursing in the home. in the school health services.Fifty per cent. of the There are nursing homes for the bed -ridden, and many school medical officers are assisted by a school nurse, private homes; several municipalities run one or more and the remainder by an administrative assistant.In nursing homes themselves.There are health services 1955 nearly 32 000 children were sent to health camps for the treatment of specific diseases such as tuber- on the advice of school medical officers.There are culosis, diabetes, poliomyelitis, asthma, cancer, rheu- 56 child guidance clinics in various parts of the coun- matism, and heart and vascular diseases.Most of try.There are also special schools for mentally them are run by private initiative and subsidized by defective and physically handicapped children. the State or local authorities.There are 10 centres For many years health education has been carried for polio patients and three centres for asthma patients. out by the various voluntary organizations, through Health care for the aged is also mainly in the hands direct contact between the physicians and the people of private associations.Since 1953 the Netherlands and, more particularly, through the district nurses, Federation for the Care of the Aged has acted as a who play a most important part in this respect. co- ordinating body.The task of the Government Mental health care is the responsibility of the Mini- in this field isstill confined to allocating subsidies ster of Social Affairs and Public Health with the and stimulating study and planning. assistance of the Chief Medical Officer of Mental About 88 per cent. of all premises were provided Health; the latter is in turn assisted by a number with drinking -water at the end of 1956, and the pro- 282 FIRST REPORT ON THE WORLD HEALTH SITUATION portion of those connected to a sewerage system was before and after slaughter.Condemned meat (in- only a little smaller.The water supplied by each cluding the carcasses of slaughter animals) is pro- of the country's 193 waterworks is controlled four cessed under the Destruction Act into animal meal times a year by the State Supervision of Public Health. and technical fat.There are twelve destructor plants, In the interests of public health, all slaughter animals which are obliged to collect and process all such (including those slaughtered at home for consumption material for destruction in the districts assigned to in the owner's household) are liable for inspection them.
NORWAY
Norway forms the northern and western part of the Scandina- arate offices, one dealing with legal aspects and the vian peninsula.Its coastline is long and indented with many other with technical aspects of health services, were winding inlets (fjords) and is fringed with a large number of rocky islands.The surface is mountainous, consisting of ele- amalgamated to form the present Directorate of vated and barren tablelands, separated by deep and narrow Health Services, with a medical expert as its chief valleys.The cultivated area is about one -fortieth of the country; administrator.The Director -General of Health Ser- forests cover nearly one -quarter; and the rest is highland pasture vices plans the budget for the entire civilian health or trackless mountain.The influence of the Gulf Stream makes the temperature higher than the average for the latitude.The services.He haswide powersof appointment, climate is maritime.The area is 324 000 square kilometres. and is the chief government consultant on all matters The population at the census of 1950 was 3 278 546, and in requiring specialized medical knowledge.At present 1956 was 3 448 673.The population is uniform, apart from the Directorate has eight bureaux: about 20 000 Lapps (called Finns in Norway), mostly in Finn - mark in the north, and about 8000 Finnish population.Almost (1)MedicalPersonnel,employingabout500 68 per cent. of the population are rural.The general education of the people is at a high level. districtdoctors, town physicians and chiefcity For administrative purposes, the country is divided into the medicalofficers.All doctors outside thedistrict cities of Oslo and Bergen and 18 Fylker, each of which is gov- system arelicensed and supervised throughthis erned by a chief executive official (Fylkesmann).There are office, which also administers the nursing and mid- 44 municipalities, 22 towns and 680 rural communes. The chief industries are agriculture and forestry, mining, wifery services. manufactures, fisheries, whaling and shipping.Manufacturing (2) The Bureau of Finance and Employment. industry is aided by the tremendous resources of water power, of which over two million kilowatts are utilized- rather less than (3) The Tuberculosis Bureau, which controls the one -quarter of the potential. service throughout the country and runs eight sana- Education is compulsory and free between the ages of 7 and 14. The schools are maintained by local taxation with government toria owned by the Government.The State also grants -in -aid.Secondary schools are provided by the State, pays the operating deficit of a number of private the local authorities and private initiative.There are univer- sanatoria. A separate division of the bureau deals sities at Oslo and Bergen, with nearly 4000 students in 1953. with x -ray programmes, tuberculin- testing and BCG The Norwegian mercantile marine is very large.The chief vaccination.One of its most important tasks today ports are Oslo, Bergen, Trondheim, Stavanger and (for iron ore) Narvik.There are nearly 50 000 kilometres of public is the rehabilitation of tuberculosis patients. roads, of which about half are main roads.The length of (4)The Bureau of Psychiatry, which administers State railways in 1953 was 4390 kilometres, of which 1130 were electrified.The Danish, Norwegian and Swedish airlines are the mental hospitals operated by the Government. now combined into one service. It is also in general charge of patients suffering from There is a comprehensive group of social security schemes. all forms of mental disorder, including epileptics and General unemployment insurance was introduced in1938. the feeble -minded. Health insurance for all workers and employers has been in operation since 1911.Workmen's compensation for industrial (5) The Bureau of Hygiene is primarily responsible workers goes back to 1895 and the scheme for sailors to 1913, for environmental services, and its work includes and for fishermen to 1909.Old -age pensions were introduced the supervision of houses, schools, hotels and industrial in 1936 and family allowances in 1946.In 1954 about 1 130 000 were covered for sickness and maternity benefits, three million establishments (in so far as this is outside the sphere for medical care and 770 000 for unemployment. of State labour inspection).The bureau also super- vises maternal and child health, and deals with Health communicable diseases and all preventive measures Since 1913, the Ministry of Social Affairs has been in the personal field.Inspection of the manufacture responsible for health services, but in 1945 two sep- and sale of food isanother important function. EUROPEAN REGION 283
Bacteriological and serological research is supervised matters was assured from the very beginning of modern by this department through the National Institute for medical development by a law passed in 1860 and still Public Health in Oslo, and the National Bacteriological in force.This law gave local authorities in each Laboratory in Tromso, as well as through the research commune responsibility for all health matters by laboratories of the hospitals.Finally, the Bureau providing for local boards of health which should be of Hygiene handles all matters involving international elected by the communal council and at least partly health work. from their members.As a governmental institution, (6)The Bureau of Dentistry was originally con- the local board of health is not subject to the control cerned primarily with schools, but it has now expanded of the mayor or chief officer of the commune.Its to offer preventive and general care to the whole decisions are subject to appeal to the Ministry of population. Social Affairs, and this Ministry or the King in Council can alteritsrules.Affairs involving sanitary or (7) The Bureau of Pharmacy organizes and directs health matters cannot usually be tried in a court of all Norwegian pharmacies and drug stores.Itis law. responsible for the employment of pharmacists, and There is a distinct tendency towards uniformity has an inspectorate to deal with poisons and other in communal health regulations.They usually con- materials dangerous to health. sist of sanitary measures regulating such matters as (8) The Bureau of Hospitals handles a nation- drinking -watersupplies,drainageandsewerage, wide plan for the development of the hospital system, housing standards and places of work.These local including employment, remuneration and working regulations are in effect applications of the national conditions and fees for medical care, and central law. purchasing of food and equipment. A special con- With the increasing complexity of the health sérvices, sultant has been appointed to deal with technical the larger areas have established departments of health aspects of the hospital service. with staffs of full -time trained specialists. In Norway the public health officer is a physician Norway is at present divided into 389 health dis- who has comprehensive duties and a wide responsibility tricts, each of which includes on an average two over a comparatively small geographical area.He not communes.The actual size of district varies greatly, only represents the national medical administration with an average of about 5000 people in each.In in hisdistrict, but is also the local health officer the health district, when it consists only of a single in the widest sense, undertaking sanitary inspection town, the doctor is called the town physician; in the and promoting social hygiene and all preventive health larger cities, he is chief city medical officer.In the work. Many of these doctors are, in addition, in provinces there is a provincial public health officer. medical practice,having direct contact with the In order to provide the doctors in remote areas with people in their homes.The doctor is paid directly trained assistants,the National School of Public by the State for his administrative and health work, Health Nurses was founded in 1947.This service and is also entitled to earn fees under the health has proved of the utmost value, as the doctor and the insurance programmeasapractisingphysician. nurse make up a local team which can plan and In approximately one -third of all health districts in carry out a very effective service.The provincial the country the public health doctor is the only public health officers are the immediate supervisors physician. of all the district health officers and town physicians. The birth rate has been falling slowly and was In addition they oversee doctors in private practice, 18.6 in 1954.The death rate has also been falling dentists, midwives and other health personnel, and and reached 8.6 in the same year.The infant mor- are also supervising officers for mental patients under tality figure, too, has been declining steadily and public care in communal and private hospitals and reached 20.6 in 1955. other medical institutions.At the same time they Maternal and child health centres are maintained are advisersto the provincial government onall chiefly by voluntary health organizations, with State health matters. support usually by direct grants for establishment By July 1956 there were 18 provincial public health and the cost of maintenance.By 1January 1956 officers (13 full- time), 372 district health officers, 22 there were 1325 of these health centres, 86.5 per cent. town physicians and 14 chief city medical officers. being maintained by voluntary organizations and the Every commune nominates a health board and its rest by municipalities.Of these centres 571 supervise chairman is now in most instances the district public expectant mothers and 117 give advice on birth control. health doctor.Communal self -government in health The usual experience is that most women prefer to 284 FIRST REPORT ON THE WORLD HEALTH SITUATION consult their private doctor or midwife for health 125 beds) were in operation by the end of 1956. supervision in pregnancy and the post -partum period, These clinicsco- operate with a number of small and also in family planning.During the period treatment homes, to which patients may be referred. 1954 -56 an increasing number of health centres had Patients needing medical supervision after being extended their services to include physical training in hospital are referred to their private doctor, either for expectant mothers and health supervision of house- directly or after a period in a convalescent home. wives.Most health centres offer vaccination and Rehabilitation and resettlement are at present under immunization.The health supervision of children consideration by a committee, with a view to re- includes medical examination, advice on nutrition organizing the system.Between 1954 and 1956 the and home care, and, when necessary, referral for number of such institutions was increased from four treatment. to five and the number of beds from 266 to 294. In urban districts the school authorities are required The dental care programme, which isavailable to employ medical officers.In rural areas, the service in four provinces, offers free treatment to children depends on the funds available, but in all higher between 6 and 18 years and treatment at fixed rates schoolshealthservicesarecompulsory.Inthe for the rest of the population. A school dental 1954 -56 period, the health examination of pupils serviceis provided by law in urban areas.The entering school was practically 100 per cent.Tuber- Government refunds 12.5 per cent. of the salaries culin- testing was universal, and BCG vaccination was of dentists in urban districts and 25 per cent. in rural carried out in the sixth or seventh year of primary areas.By 1954 -56 the programme covered approxi- school.In 1956 approximately 90 per cent. of the mately 80 per cent. of all schools. children in primary schools were given, on a voluntary Since 1945, health services in industry have expanded basis, two injections of polio vaccine. considerably, and by the end of 1956, 800 factories No specific organization has been set up for health with more than 215 000 employees were covered. education of the public.The National Directorate In recent years increasing emphasis has been placed issues educational material mainly related to child on the rehabilitation of the physically disabled, but health and the prevention of tuberculosis.Health comparatively little is being done for the systematic education of the public forms a major part of the health care of the chronic sick.Voluntary health programme of voluntary organizations. organizations have been very active in this respect, The Bureau of Vital Statistics within the National introducing projects for health care and social services. Central Statistics Bureau deals with all information One of the major voluntary health organizations, the concerned withthehealthservices.An annual National Association against Tuberculosis and for publication - " Medical Statistical Report " - is a Public Health, has in recent years taken a great interest most comprehensive source of information on these in the care of the aged.In co- operation with the data.There is also a Norwegian Cancer Registry, Institute for Social Medicine in Oslo and the Society Certain items, such as statistics on mental hospitals, for Gerontology, this voluntary body has undertaken accidents, etc., are published separately. a comprehensive study of problems of old age.In In the home, medical care is provided by general Oslo there are now nine welfare centres for the aged, practitioners and specialists and by parochial nurses. offering cheap meals, leisure -time occupation, help No general scheme of home nursing has yet been with personal hygiene, help in the home, etc.There is approved.In dispensaries and health centres (which an increasingtrend towardsbuilding apartment are institutions for diagnosis and health supervision) houses for elderly people, with all necessary medical no significant amount of medical care is given.In facilities. 1956, Norway possessed 221 general hospitals, with The National Institute for Public Health and the 18 800 beds; 22 mental hospitals, with 6631 beds; Bacteriological Institute at Tromso are the principal 28 nursing homes for the mentally deficient; one nurs- State laboratories.Facilities for diagnostic services ing home for epileptics, with 101 beds, and one are also available in the local health department in leprosarium, with 15 beds.In 1955 there were 76 Oslo and Bergen, and to a limited extent in other tuberculosissanatoria and nursinghomes,with cities.The University Institute for Hygiene and the 4168 beds, but in 1956 the number of beds had been InstituteforOccupationalDiseasesaremainly reduced to 3420.There are also about 450 beds in engaged in research. psychiatric in- patient clinics, the majority of them The medical faculties of the Universities of Oslo and in Oslo. Bergen have a student body of 550 and 100 respectively, For child guidance and the treatment of psychiatric and graduate an average of 95 doctors each year. disorders in children, four out -patient clinics (with Dentists are trained at the Norwegian Dental High EUROPEAN REGION 285
School, which has a student body of 200 and graduates end of 1956 this proportion was reduced to 12 per approximately 50 students each year. cent.Control of water pollution is the responsibility As regards environmental health, by the beginning of the local health authority.Water plants serving of 1954 it was estimated that about 17 per cent. of more than 1000 consumers must be approved by the the population did not have running water.By the Ministry of Social Affairs.
POLAND
Poland is situated in Central Europe, most of the country being some 100 000 kilometres were hard surface.Air transport is part of the great European lowland.It is bounded by the developingsteadily;in1949thenationalairlinecarried Carpathian mountains on the south (forming its frontier with 64 547 passengers, while in 1957 the number had increased Czechoslovakia), by the German Democratic Republic on the to 224 276.The merchant marine, in1948,consisted of west, by the Union of Soviet Socialist Republics on the east and 45 ships with a total tonnage of 159 277; by 1957 it had 84 ships north -east, and by the Baltic sea on the north.The two main (including 23 of 5000 -10 000 tons), with a totaltonnage rivers -the Vistula and the Oder -flow into the Baltic.The of 295 412.The three main ports on the Baltic are Gdynia, total area of Poland is 311 730 square kilometres.The climate Gdafisk and Szczecin, and smaller ports include Kolobrzeg, is semi -continental. Darlowo and Ustka. The population at the 1946 census was 23 930 000; in 1950 it Education is free and compulsory up to the age of 14.In had increased to 25 million, and by 1957 it was estimated to be the 1957 -58 school year there were 24 502 elementary schools, 28.5 million.Warsaw, the capital, has a population of over with a total of 3 924 179 pupils.Secondary schools, vocational one million.The average density of the population is 92 per schools and schools of art are being developed.There are square kilometre, though higher in the industrial areas -in 76 institutions for higher education, including seven universities Katowice voivodship (Silesia), for instance, it is as high as 331. -in Warsaw, Lodi, Poznafi, Kraków, Lublin, Tomb. and Rural dwellers accounted for 68 per cent. of the population Wroclaw -which had a total student body of 162 680 in the in 1946, but by 1957 this percentage had fallen to 54; the academic year 1957 -58.Pupils of secondary and vocational movement towards the towns is related to the comparatively schools as well as college and university students benefit to a rapid industrialization of the country. large extent from State scholarships, and school and students' Poland is a Democratic People's Republic.Parliament is the hostels are also provided for them. supreme State authority in charge of legislation and with control over the activities of other State agencies.The State is repre- sented by the Council of State, chosen from among the members Health of Parliament.The Council of Ministersisthe supreme executive and administrative authority; the local authorities are The characteristic features of the Social Health the People's Councils, elected directly by the citizens.The Service in Poland are: (a) responsibility of the State country is divided into administrative units, or voivodships, for the health of the population; (b) uniform super- which in turn are subdivided into districts, and these into rural vision by the Ministry of Health of the essential communes.There are in all 17 voivodships, 398 districts and 8339 rural communes. The five largest towns -Warsaw, Lodi, public health problems, while at the same time the Poznañ, Kraków and Wroclaw -have their own administrative independence of the local health service authorities authorities equivalent to a voivodship, and within the districts ismaintained;(c)the principle of planning the there are 76 towns which have a separate administration equal development of the health services in accordance in rank to that of the districts. Before the war, the economy of Poland was mainly agricultural; withtheco- ordinated programme for economic the present economic structure of the country, however, shows development of the country; (d) correlation of the a continuous trend towards industrialization.The chief in- organization of the health services with the achieve- dustrial region is Silesia, and heavy industry is the principal ments of science; and (e) increasing emphasis on branch of production, including locomotives,rolling- stock, preventive medicine.The health programme has motor vehicles, aircraft, ships, agricultural machinery, machine- tools, etc.Other centres of heavy industry, apart from Silesia, been carried out along these lines since 1944. are the voivodships of Kraków (Nowa Huta) and Kielce, and the Before the war, health problems were included cities of Warsaw, Lublin, Wroclaw, Poznañ, Szczecin, Gdañsk, in the activities of the Ministry of Labour and Social and Gdynia.Other industries are based mainly on Poland's Welfare, the Ministry of the Interior and the Ministry raw materials, such as hard and brown coal, petroleum, natural gas, salt, potassium salts, timber, limestone, sulphur and gypsum. of Education, and were also dealt with by voluntary There are several centres of the textile industry, the chief one agencies.The Ministry of Health was established being the town of Lodz.Agriculture is based on four grain as the supreme authority in health matters in 1945, crops -rye, wheat, barley and oats- and on two root crops - and the final structure of the present health service potatoes and sugar beet. organization was worked out during the period of The development of industry has its parallel in the develop- ment of transport.In 1957 there were 27 211 kilometres of the three -year plan,1947 -49, and of the six -year railways, and about 280 000 kilometres of public roads, of which plan. 286 FIRST REPORT ON THE WORLD HEALTH SITUATION
At the local level of the voivodships, districts and In 1957, there were 3679 general out -patient clinics, urban districts, responsibility for health is in the hands of which 1906 were attached to institutions; 1401 of the health service departments of the People's health centres (1033 of them in rural areas); 2573 Councils.These departments are under the admini- health stations (or sub -centres); and 3351 maternity strative control of Boards of the People's Councils, stations (of which 1938 were in rural areas). Emergency and under the technical control either of health assistance is being organized to an increasing extent: departments of higher rank, or of the Ministry of in 1950, there were 178 first -aid centres, while in Health.Professional supervision of the health service 1958 there were 361 centres and 20 air transport institutions is also carried out by voivodship specialists teams. (of whom there were 197 at the end of 1957) appointed The birth rate in Poland is high: in 1957 it was by the Minister of Health.In certain specialties 27.5.The death rate was 9.0 in 1957, and the infant there are also national specialists (of whom there mortality rate, although still high, has decreased from were 25 at the end of 1957), who co- ordinate the work 136 in 1937 and 111 in 1950 to 77.0 in 1957. of voivodship specialists and also act as advisers The control of communicable diseases and sanita- for the relevant departments of the Ministry of Health. tion, food control, housing, school hygiene, occupa- Furthermore, there is an advisory Scientific Council tional hygiene and public utilities are under the at the Ministry of Health. supervision of a State Sanitation Inspectorate which Special institutes have been established to plan, is directed by the Ministry of Health.The General organize and carry out research work in various Sanitary Inspector, who isin charge of this unit, branches of medicine.There are at present 14 such acts as deputy to the Minister of Health in sanitation institutes, including the State Institute of Hygiene, and epidemiological questions.Every voivodship, the Institute of Maternal and Child Health, the district, town and urban district has a sanitary - Tuberculosis Institute,theInstitute of Oncology, epidemiological unit in the charge of a sanitary and the Institute of Occupational Diseases in the Textile epidemiologicalinspector,andaboutone -third and Chemical Industries, the Institute of Occupational of these units have fully equipped public health Diseases in the Coal and Metallurgical Industries, laboratories.The State Sanitation Inspectorate co- and the Institute of Haematology.There are also operates with all other government departments and 28 medical associations. other bodies whose activities come within its sphere All forms of health service are available to everyone, of influence; it enforces legislation connected with either free of charge (to insured persons, who form public hygiene and epidemiology on the basis of a about 60 per cent. of the population) or at reduced decree which gives it extensive powers, and it works or full fees.All preventive facilities and all provision out standards and sanitary regulations. for treatment of communicable diseases are free of Vaccination against typhoid, smallpox and diph- charge to all, whether insured or not.Out -patient theria is compulsory for children up to seven years of care is organized by the local health units to cover age; vaccination against tuberculosis is compulsory their respective areas, and includes basic services such for the new -born, children and young people up to as internal medicine, paediatrics, obstetrics, gynae- 18 years of age. cology, dentistry and sanitary- epidemiological ques- Among communicable diseases which are significant tions, as well as specialized services. problems in Poland are typhoid, common infectious The number of hospitals and sanatoria is continuous- diseasesofchildhood,andinfectioushepatitis. ly increasing, although it is not yet sufficient to meet Poliomyelitis has been fairly prevalent, particularly the needs of the population.The number of beds in since 1951; immunization is practised to an increasing health establishments (including those for mental extent, and the production of poliomyelitis vaccine care) has increased as follows between 1938 and 1957: began recently. Tuberculosis control is one of the foremost problems Number Index of beds per 1000 of the Social Health Service.In 1957, 600 000 pa- 1938 69 361 2.01 tients were registered at the tuberculosis dispensaries; 1949 93 048 3.76 of these some 400 000 were activecases.These 1957 148 963 5.22 dispensaries are the basic units in the tuberculosis control organization; in 1957 there were 509 of them. Climatic treatmentisalsodeveloping;thereare In the same year, there were 10 470 beds in hospitals 24 health resorts, with a total of some 12 000 beds. and 22 686 in sanatoria for tuberculosis patients. Among the largest may be mentioned Krynica, There were also 8402 preventorium beds for children Ciechocinek, Busko, Cieplice and Szczawno. up to 14 years of age; 1285 beds for students, and EUROPEAN REGION 287
337 beds in night sanatoria for workers.The tuber- preventiveincharacter,butgeneralout -patient culosis mortality rate is decreasing steadily: in 1949 clinics also have sections devoted to school hygiene. it was 113 per 100 000, while in 1956 it was 51.0.The The organizationof voivodshipdispensariesfor number of newly detected cases is also decreasing: school hygiene is planned for the near future. whereas in 1949 the rate was 496 per 100 000, by 1956 The care of mothers and children is regulated by it had fallen to 327.Attention is turning more and law.Special legislation on family questions and more to the problem of the handicapped, and medical regulations for social insurance determine, inter alia, and vocational rehabilitation of tuberculosis patients the hours and conditions of work of expectant and is gaining in importance. nursing mothers, the granting of maternity leave Venereal disease control consists of compulsory (12 weeks), and maternity benefits.In 1956 a law treatment of patients and contacts.Between 1948 was passed laying down the conditions under which and 1950, a mass campaign carried out by the Social induced abortion is permissible. Health Service resulted in a considerable decrease With the growing industrialization of the country, in the syphilis morbidity rate, which was maintained great attention is being paid to the industrial health until 1954.In recent years, however, the rate has service, which, although essentially preventive, also been found to be rising again; for example, in 1947 the providesmedicalcare.Specialemphasisislaid number of registered newly discovered cases of syphilis on work safety and hygiene.In 1957, the number was about 100 000, or a rate of 500 per 100 000; in 1955 of hours worked by physicians in the industrial the number fell to 2681 (a rate of 9.7), but in 1957 health services amounted to 3 178 215, not including it had increased to 5515, or a rate of 19.1 per 100 000. dentistry; 687 922 initial medical examinations, 959 283 The incidence of gonorrhoea shows a tendency to periodic examinations, and 14 270 442 consultations decrease; 39 039 cases were registered in 1955, and were carried out.The industrial health service is 27 979 cases in 1957. being organized mainly in such key industries as Otherdiseaseswhichareimportant problems coal mining, foundries, chemical factories, engineering include the rheumatic diseases and malignant tumours. works and textile factories. A special department in the Ministry of Health Mental care is in the charge of the Section of Mental is in charge of maternal and child welfare, and the Diseases Control in the Ministry of Health and the localhealthauthoritiesalsohave corresponding corresponding sections at the local level.There are departments.The Institute of Maternal and Child 26 psychiatric hospitals, four neuro -psychiatric sana- Health deals with the scientific and organizational toria for children, and three sanatoria for adults; aspects of this subject.Great emphasis is laid on the total bed capacity is about 27 500.Institutions preventive care; there is a wide network of pre- for chronic mental patients not requiring treatment natal clinics and of clinics for both healthy and sick and for mentally backward children are run by the children.In 1957 there were 18 681 beds in obstetrical Ministry of Labour and Social Welfare, the Ministry and gynaecological wards of hospitals,including of Education, and theCaritas Association.The special beds for premature infants.There were also increasing morbidity of mental diseases and neuroses is 10 316 hospital beds for children. probably related to growing industrialization and the Crèches for infants between six weeks and three stress of present -day life. years of age are organized to provide proper care for Great importance is attached to health education children whose mothers are working.The number of the public.There is a special Health Education of places in these crèches has risen from 18 866 in 1949 Section in the Ministry of Health, and the scientific to 50 559 in 1957.There are also homes for small basis of the programme is elaborated at the State children who are abandoned or orphaned, or whose Hygiene Institute.Numerous publications dealing parents for justifiable reasons cannot provide for with health education are issued.The propagation them; in 1957 there were 73 such homes with accom- of health education is also one of the tasks of the modation for 5476 children.Special rehabilitation Polish Red Cross. centres have been organized for children between the In spite of continuous though slow improvement in ages of 3 and 14 years who require either a special every respect, the general level of environmental climatic cure or rehabilitation after certain diseases, sanitation in the country is still not satisfactory, and such as poliomyelitis or rheumatic fever. much progressisneeded in health education of The health services are responsible for the provision the population and inthegeneral standards of of medical and health care at educational institutions hygiene. for children and young people between the ages of Development of the health service depends on having 3 and 18 years.The school health services are mainly a sufficient number of professionally well -qualified 288 FIRST REPORT ON THE WORLD HEALTH SITUATION staff.As the following table shows, there has been work.Studies at the medical faculties last for six an encouraging increase in health personnel in recent years, and the courses in dentistry and pharmacology years: last for five years. In the academic year1957 -58,a 1938 1949 1955 1957 total of28 391students attended the medical schools. Physicians 12917 8735 18373 22405 Post -graduatecoursesforphysiciansarealso Dental surgeons 3686 1756 6876 8011 organized. Pharmacists 3787 3455 6276 7023 Nurses 6674 11238 49278 53672 The training of para- medical personnel is carried Midwives 9356 6896 7689 8359 out in special schools.There are at present59schools Feldshers 1403 591 5447 6656 for nurses,17 for midwives, eight for laboratory technicians, and some other institutions.In spite of The training of physicians, dentists and pharmacists the very considerable increase in the number of trained is undertaken at 10 schools of medicine (in Bialystok, nurses in recent years, the shortage of this type of staff Gdalísk, Katowice, Kraków, Lublin, Lodz, Poznalí, is still most acute. Szczecin, Warsaw and Wroclaw).Apart from teach- Future plans include the development of the pre- ing, these schools of medicine also carry out research ventive aspect in every branch of medicine.
PORTUGAL
Portugal occupies the western part of the Iberian peninsula; Welfare, which was established in1940in the Ministry it is bounded on the north and east by Spain and on the south of the Interior.The Under -Secretary is in charge of and west by the Atlantic Ocean.The Azores and the Madeira Islands in the north Atlantic are politically integrated with the four central divisions, which are the supreme autho- Republic.The physical features of the country vary greatly, rities in matters of health and social welfare: the from the mountainous region of the Sierra da Estrella and the Higher Council of Hygiene and Social Welfare; the extensive moorlands below, to the wide plains which slope Directorate -General of Health; the Directorate -Gene- down to the sand dunes and lagoons of the coast.The climate is equable and temperate, though severe inland towards the ral of Welfare; and the Social Welfare Inspectorate. north.The area of the mainland is 92 161 square kilometres. The Directorate -General of Health is made up of The population of Portugal at the 1950 census was 8 441 312, the following technical sections: sanitation, preven- and in 1956 it was estimated at 8 836 850.About 70 per cent. tion of infectious and social diseases; rural health and of the people are rural.The chief occupations are agriculture, malaria control; industrial and occupational health; stock- breeding and fishing (in which 1 569 120 people, or 49 per cent. of the working population, are engaged), followed by food hygiene and bromatology; child health; sanitary industry and commerce (1 117 460, or 34 per cent.).Other control of ports,frontiers and public transport; occupations engage 509 902 people, or 17 per cent. of the pharmaceutical practice and control of drugs.There working population.Lisbon, the capital, has a population of is also an Administrative Services Office to which 800 000.In 1950 it was estimated that 58:2 per cent. of the population over 10 years of age were literate. is attached a Supplies and Equipment Section; the For administrative purposes the country isdivided into latter is a public health depôt where equipment is 11 provinces, 18 districts (four in the islands), 304 communes, kept for disinfection and insect control, for setting and 3956 parishes, including 186 in the islands. up isolation centres and for other public health The economy is predominantly agricultural.The chief pro- purposes, as well as cars, ambulances, disinfection ducts are cork, wheat, maize, rice, fruit, timber and wine. The six-year development plan, 1953 -58, provides for important vehicles, tank lorries and so forth.Although not hydro -electric development, irrigation, expansion of agricultural sections in the administrative sense of the word, lands, afforestation, a steel and tinplate industry, and extensions there are also units for sanitary engineering, medical to the petroleum refinery near Lisbon. inspection of medicinal mineral water, and health The chief ports are Lisbon, Oporto and Setúbal.Portugal has a large merchant marine, and a very considerable amount education. of trade is carried onthroughthe ports.In 1955, the total In addition to activities of a purely social nature length of railways was 3589 kilometres; there were 29 709 kilo- and those relating to the administration of hospitals, metres of roads on the mainland and 1840 on the islands. the Directorate - General of Welfare is also responsible, Lisbon has an international airport through which about 19 air- through the Maternity Institute, for all medical and lines operate services.There are two civil airlines, an inter- island service, and other services in Portuguese East and West social assistance to mothers and to children up to Africa. the age of seven years; through the National Institute for the Welfare of Tuberculosis Patients, for assistance Health intheprevention and treatment of tuberculosis At the national level, the health services are directed and attention to its social aspects; through the Insti- through the Under -Secretariat of State for Social tute for the Welfare of Leprosy Patients, for assistance EUROPEAN REGION 289 in the treatment of leprosy patients and their rehabilita- insurance, 7006 nurses and 870 midwives and health tion and subsequent follow -up; and through the visitors. psychiatric centres, for medical and social assistance Mortality statistics are collected and published by to persons suffering from mental disorders. the National Institute of Statistics in close collabora- The Ministries of Labour and Social Insurance, tion with the Health Department.Data relating to of Economy, and of Education are responsible for communicablediseases,vaccinationsandspecial social insurance and industrial hygiene, the control surveys undertaken by the health services are collected of zoonoses, and school health and sports medi- by the Health Statistics Section of the Health Depart- cine, respectively.The Portuguese Cancer Institute ment for compilation and analysis.The birth rate and the Camara Pestana BacteriologicalInstitute has changed very little during the period under review, are under the Ministry of National Education, and being 22.7 in 1954, 23.9 in 1955, and 22.9 in 1956. the Institute of Tropical Medicine is under the Ministry The general mortality rate was 10.9 in 1954, 11.3 in for Overseas Territories. 1955, and 12.1 in 1956.Infant mortality rates for At the regional or provincial level, regional health the same years were 85.5. 90.2, and 87.8, respectively. authoritiesrepresenttheDirectorate -Generalof Among the principal causes of death registered Health in the chief towns of all the districts in the during the years 1954, 1955 and 1956, were diseases country; there are also State and regional hospitals, of th hearet and vascular system, pneumonia, tuber- bodies delegated by the National Institutes under culosis, malignant neoplasms, gastro- enteritis, and the Directorate -General of Welfare, and provincial diseases of early infancy.Typhoid fever, diphtheria social welfare committees. and whooping -cough head thelistof notifiable At the local level, there are communal health services communicable diseases. under the district health authorities, local hospitals The control of communicable diseases is the res- under voluntary organizations, communal medical ponsibilityof theDirectorate - Generalof Health officers (who give free medical care to the needy), in the Ministry of the Interior, but tuberculosis and and communal and parish social welfare committees. leprosy control work is under the direction respectively The communal medical officers are members of the of the National Institute for the Welfare of Tuber- communal health services and, as such, assist the culosis Patients, and the Institute for the Welfare of communal health officers in carrying out their duties Leprosy Patients.Control of malaria, yellow fever, and responsibilities. kala -azar, bilharziasis and relapsing fever is in the Voluntary and charitable associations play a very charge of the technical section for rural health and important role in health and social welfare in Portugal. malaria control in the Directorate - General of Health. The services in the charge of the Under -Secretary The local health services, the health centres and the of State for Social Welfare, operating at the various communal medical officers carry out vaccinations and levels,are responsible for directing, co-ordinating other preventive measures in outlying areas.Dis- and supervising all the medical and social activities pensaries and health centres under the local health carried out by these voluntary agencies. authorities provide services for the control of venereal There are government health centres or dispensaries diseases and trachoma. in all the major towns, financed by the Directorates - Therearecommunicablediseasehospitalsin General either of Health or of Welfare.There are Oporto, Coimbra and Lisbon, and many other general also health centres, commonly known as " social hospitals have special wards for the isolation of infec- welfare posts " run by voluntary societies but financed tious cases.Only smallpox vaccination is compulsory ; in whole or in part by the Directorate -General during the years under review, 633 833 persons were of Welfare.These centres, which usually provide vaccinated and 1 914 637 were re- vaccinated. medical care services, are scattered throughout the Although tuberculosis is not compulsorily notifiable, country, including the rural areas.There is a growing available data show that the tuberculosis mortality tendency nowadays to convert the hospitals into rate has fallen considerably during recent years; effective health centres. in 1941 it was 160.5, decreasing to 133.1 in 1951, In1953, insurance covered nearly one million and since then there has been a marked decline to people for sickness and maternity benefits, 1.5 million 62.2in1956.Tuberculosiscontrolservicesare for medical care, and 173 000 for industrial accidents. provided through three centres for prevention and In 1956, there were 20 043 medical and auxiliary diagnosis in the north, centre and south of the country, personnel working in the country's health services, with supporting services consisting of 12 mobile including 272 local health officers, 805 communal x -ray units, 13 mobile vaccination teams, a number of medicalofficers,2898physiciansundersocial districtcentres and vaccinationposts,85 health 290 FIRST REPORT ON THE WORLD HEALTH SITUATION centres and 58out -patientclinics.Furthermore, schools the services of doctors are made available there are 7422 beds in sanatoria for pulmonary by the National Ministry of Education. A school tuberculosis and 1261 beds for tuberculosis of the canteen system has been instituted in recent years, bone, 739 beds in preventoria, and 395 beds at the and has helped to improve the nutritional status thoracic surgery centre.The tuberculosis control of children from needy families. campaign was considerably intensified in 1956, and Health education of the public is carried out prin- during the first quarter of that year 379 101 tuberculin cipally through the annual organization of health tests, 148 960 BCG vaccinations and 732 632 x -ray exhibitions in the large towns and rural centres. examinations were carried out.The rehabilitation With regard to occupational health, legislative pro- of tuberculosis patients is receiving active considera- vision has been made for the protection of the health tion, and certain pilot studies are in progress. and safety of workers, including medical care and A most successful campaign against Aëdes aegypti compensation incasesof occupational accidents undertaken between 1950 and 1956 resulted in the and diseases.Other ministries intheirrespective eradication of this vector and the suspension in 1957 fields also provide certain services in this connexion. of the quarantine measures relating to yellow fever. In regard to chronic diseases, the activities of the Malaria control measures resulted in the protection Portuguese Rheumatological Institute are noteworthy. of some 225 000 persons in 1954, 141 125 in 1955, There are four universities in Portugal, three of and 230 250 in1956.The number of confirmed which have medical faculties with a total of about cases of malaria, including relapses, dropped from 200 graduates each year.The fourth is a technical 483 in 1954 and 255 in 1955 to 130 in 1956.In some university in Lisbon, which has a School of Engineering areas, malaria eradication has been or is about to be and an Advanced School of Veterinary Medicine. completed. There are also the Institute of Tropical Medicine, the Kala -azar isstillfairly prevalent in the north, National Institute of Physical Education, and the where 214 cases were reported in 1956.On the other Ricardo Jorge Higher Institute of Hygiene, which hand, the only focus of bilharziasis in the country provides general courses on public health for the has beenpracticallyeliminated.Relapsing fever benefit of candidates for the posts of health officers or remains localized almost exclusively in the Upper communal medical officers. Alemtejo and only three cases were reported in 1956. Among the privateestablishments,the Lisbon The usual diagnostic laboratory services are available Social Service Instituteand the Coimbra Training in different parts of the country.For the public School both train social workers.For the training health services, more -specialized analysis and research of nurses there are, among other institutions, the work is undertaken by the Ricardo Jorge Higher Technical School of Nursing and the Artur Ravara Institute of Hygiene in Lisbon, under the auspices School.The Maternity Institute operates schools in of the Directorate - General of Health. Lisbon and elsewhere which providespecialized Maternal and child health services are provided training in maternal and child health. through the local health centres, and in many places During recent years the Government has continued maternal and child health clinics have been established its policy of improving water supplies in towns and under either public or private auspices.Itisre- villages.It is estimated that 96 per cent. of the urban cognized, however, that these services are not yet population is supplied with water.Work has begun sufficiently developed to meet present needs. on the construction of more complete sewerage Medical inspection in primary schools is carried out systems - eitherthroughtherenovationof old by the communal medical officers.In the secondary systems or through the installation of new ones.
ROMANIA
The People's Republic of Romania is in south -east Europe 40.9 per cent. is arable land and 27.1 per cent. is wooded.The and is bordered by Bulgaria, Yugoslavia, Hungary, Czechoslo- climate is continental. vakia and the Union of Soviet Socialist Republics.To the At the 1956 census, the population was 17 489 450, with an east it has a coastline of 245 kilometres on the Black Sea.The average density of 73.6 per square kilometre; 31.3 per cent. of main physical regions of the country are the plain of Wallachia, the people were urban and 68.7 per cent. were rural.Bucarest, the mouth of the Danube, Transylvania (for the most part a the capital, had a population of 1 236 908. fertile plateau, bounded by the Carpathians on the north, east Romania is a socialist people's republic, divided for adminis- and south), Moldavia, which is heavily wooded, and the Dobruja trative purposes into 16 regions, with populations varying from steppes.The total area is 237 500 square kilometres, of which 500 000 to 1 500 000.Each region is subdivided into districts EUROPEAN REGION 291
(from eight to 20 in a region) of between 60 000 and 80 000 in- and supervising all activities for health protection. habitants, and the districts in turn are divided into rural com- munes (of which there are 4314 altogether), with an average of The main departments in the Ministry are: Depart- 2800 inhabitants each. ment of Health and Prevention of Epidemics (sanitary The administrative direction of the regions, districts and com- and epidemic prevention units, sanitary control and munes is in the hands of the People's Councils; these bodies are regulation); Department of Curative and Preventive elected for two -year terms and are responsible within their Medicine (hospitals, polyclinics, health units, maternal respective areas for economic, administrative, social and cul- tural activities. and child health centres, tuberculosis control dispen- The country's many natural resources include deposits of saries); Department of Social Welfare (social welfare mineral oil, natural gases, radioactive metals, non -ferrous min- and pensions); Pharmaceutical Department (distribu- erals, iron ore, silver ore, salt, building materials and coal. Since tion units for drugs and other medical products); the end of the war, industry has played a leading part in develop- ing the country's economy.Agriculture, which had previously Division of Personnel and Training, and Division provided more than half the national income, now provides only of Balneo- Climatic Treatment.There are further 31.9 per cent., whereas industry's contribution is 43 per cent., divisions in charge of planning, statistics, organization based on prices current in 1956.The national economy is of work, building, equipment and supplies, organiza- governed by the socialist system.The chief branches in which tion of production of medical appliances and instru- industrial production has developed are machine- construction and metal- working (21.5 per cent.), the food industry (20.2 per ments, and questions concerning financial planning cent.), fuel production (10.1 per cent.), forestry and timber in health programmes. (8.9 per cent.), and the textile industry (8.6 per cent.). A number of scientific research institutes, whose The development of agriculture in Romania is consonant workisco- ordinated by the Ministry's Scientific with the socialist transformation through which the country is passing; mechanization and other improvements have been Medical Council, assist the Ministry of Health and introduced into agricultural work.At the end of 1957 there Social Welfare; among them may be mentioned the were 240 pools for machines and tractors, with nearly 21 000 trac- Cantacuzino Institute of Microbiology, Parasitology tors, a large number of reaping and threshing machines, and and Epidemiology; theInstitute of Hygiene and other agricultural machinery. Public Health; the Institute of Ph) siology; the In- The rise of industry and the mechanization of agriculture have changed the economic character of Romania, which in recent stitute of Paedia tries ; the Cancer Institute; the Institute years has become an advanced industrial and agrarian country. of Haematology and Transfusion; the Institute of As a result of this process of economic development and indus- Medical Appraisal of Working Capacity; the Institute trialization and of the higher level of general education, large of Chemical and PharmaceuticalResearch;the numbers of peasants have been attracted towards industry, building, transport and other work, and the increase in the Institute of Balneo- Physiotherapy; the Dermatology number of workers, engineers and technicians has wrought and Venereology Centre; the Institute of Pathological important changes in the structure of the population. Anatomy, and the Institute of Forensic Medicine. General education is free and compulsory.There are 98 fac- Scientific institutes of the Academy of Science of the ulties of different disciplines, which were attended by 80 919 stu- People's Republic of Romania, and their branches dents during the academic year 1957 -58.Most of these faculties are in the university centres of Bucarest, Cluj, Jassy, Tg. Mures throughout the country, also carry out an active and Timisoara.The Academy of the People's Republic of research programme in medical science. Romania, which is the supreme scientific institution, has numer- The Ministry of Health and Social Welfare is also ous specialized sections and branches in the main university directly in charge of a State publishing firm (" Edi- centres. At the end of 1957 there were 12 078 cultural centres and tura Medicalá "),a medical documentation centre reading -rooms in the country.The number of public libraries with branches in the chief towns of the country, a has grown considerably, and had reached 18 767 in 1957. technical health film service, and two firms producing Under the new conditions, Romania's transport system has medical instruments, prosthetic appliances, and other also developed.There are now about 100 000 kilometres of equipment. roads and 12 000 kilometres of railways.The Danube, which The five faculties of medicine and phar- is the country's chief waterway, provides facilities for water macy, the auxiliary training schools, and a number transport and also, since it runs through eight countries, for of large sanatoria and other health establishments connexions between the countries of central and south -east are also under the direct technical and administrative Europe.Romania's seaboard on the Black Sea gives facilities supervision of the Ministry. for sea transport, and the main port is Constanta, which has modern port installations, particularly for the transport of At the regional level, each of the 16 administrative petroleum and cereals.A national airline provides air services regions (as well as Bucarest) has a health and social within the country and connexions with other European coun- welfare section which operates within the framework tries. of the People's Councils and which is headed by a chief medical officer, with a staff of three medical Health officers and the necessary administrative establishment. The Ministry of Health and Social Welfare is the These medical officers are members of the public technical body responsible for planning, organizing health services. 292 FIRST REPORT ON THE WORLD HEALTH SITUATION
Each administrative region has its own health budget have serological and helminthological laboratories. and is financially responsible for all health activities Regional units are generally staffed by 15 doctors, within its boundaries. three chemists, and 16 auxiliary personnel; district The regional health and social welfare sections ensure units usually have a smaller staff of seven doctors, that the health policy within their respective areas is one chemist, and six auxiliary personnel.Medical in accordance with the standards laid down and the care of the urban population is provided through instructions issued by the Ministry.With the help hospitals with a " unified " organization - that is, of medical and social welfare units, they are also res- working in close co- operation with, and under the ponsible for medical and social assistance to the same direction as, the polyclinics and health units population.There is a social welfare office in each of a clearly defined area; by this means, both curative region to deal with problems of pensions and social and preventive needs are met.Each urban district welfare, and a regional pharmaceutical office, which is served by two general medical practitioners (one deals with the supply of drugs and medical instruments; for adults and the other for children), and by nurses, these offices are under the regional health and social social welfare workers, midwives and sanitarians; welfare sections. the polyclinics and hospitals have medical specialists The regional health and social welfare sections are on their staff, appointed in accordance with official assisted in their work of direction, co- ordination standards on the basis of the number of inha- and supervision by a medical scientific council, made bitants. up of high- ranking specialists in the different branches Medical care of workers is provided through in- of medicine, who act in an advisory capacity, giving dustrial dispensaries (served by from one to three their opinion on various health problems and on practitioners) and polyclinics(served by medical specific methods of approach applicable tolocal specialists).Larger factories have their own medical conditions. and health services consisting of a polyclinic for The chief medical officer is generally also appointed specialist consultations and a medical station (which chairman of the regional Red Cross committee in is attached to the polyclinic) with a few beds for tem- order to ensure close co- operation between the health porary in- patient accommodation. services and the Red Cross.The latter organizes In rural areas there are district dispensaries, each health education activities in factories and schools, serving about 5000 people, staffed by a physician, as well as special courses in hygiene and domestic nurses, midwives, technicians and sanitarians; many science for girls, to prepare them for the future with rural districts have also added two paediatricians and an understanding of the basic principles of health. a dentist to the staff.In future years it will be possible The Red Cross also makes up teams, headed by to increase this staff, since within the next four years doctors, to help the population carry out their own there will be 6000 more doctors.Almost all districts programmes of health improvement, and teams of have one or more small maternity clinics with five to volunteers who assist in various health activities such 10 beds, and many have their own medical station as vaccination, mass case -finding surveys, environ- where patients may stay either for treatment or while mental sanitation, and so forth. awaiting transportation to hospital. Within the framework of each district People's Health centres generally provide, apart from medical Council there is also a health and social welfare care, services in maternal and child health, health section, directed by a district chief medical officer, education, environmental sanitation (including sani- and assisted in its work by a social welfare office and tary installations), control of communicable diseases, a sanitary and epidemic prevention unit (which may vaccinations, and other matters.In certain rural serve one or more districts), as well as by the physi- districts there are, in addition, either dispensaries cian in charge of the district hospital. with special services for children or hospitals with A wide system of health establishments provides departmentsforinternalmedicine,surgery, pae- the population with medical and health care.Since diatrics, infectious diseases,etc.In small districts 1950 a specialized technical network of sanitary and the hospitals may have between 80 and 120 beds, epidemic prevention units has been set up.The whereas in larger urban districts they may have from task of these units is to prevent and control infectious 300 to 400 or more according to the number of diseases,superviseenvironmentalsanitation,and inhabitants. deal with all matters concerning industrial and school Other health establishments includeinstitutions health, food control and nutrition.The units have for the chronic sick, for psychiatric patients, for their own statistical services and bacteriological and children with various affections, and for disabled chemicallaboratories;in some casestheyalso adults; there are also special training schools for the EUROPEAN REGION 293 blind and the deaf and dumb, and social welfare units per 100 000) and from cancer (which had third place, for the aged. with a rate of 81.2). In 1938, Romania had 8234 doctors, or one for The tuberculosis mortality rate, on the other hand, every 1900 inhabitants; by 1957 this number had dropped from 180.3 per 100 000 in 1948 to 41.2 in 1957. risen to about 22 500, or a ratio of 1: 800.At the The organization of a tuberculosis control service, present time about one -third of the doctors are general including mass x -ray case -finding surveys, has made it practitioners and the remainder are specialists.There possible to discover and follow up a large number of are also many auxiliary personnel; in 1955 there were hitherto unknown sufferers, and has resulted in a some 60 000 nurses, midwives, and technicians, as reduction in case incidence (to 315.6 in 1957) as well against 17 000 in 1944. as a decline in the death rate. The cost of social insurance is borne entirely by The study of medicine, paediatrics, dentistry and the State, and includes not only medical care but also pharmacy is carried out in the five universities of State family allowances, invalidity and old age pen- Bucarest,Cluj,Jassy,Timisoara and Tg.Mures. sions, and climatic and spa treatment.With regard During the academic year 1956 -57 there were alto- to the last- mentioned benefit, some 270 000 citizens gether 7003 students in general medicine, 1462 in a year profit from a stay in a State rest -home, and paediatrics, 819 in dentistry and 865 in pharmacy. 181 000 from treatment in State sanatoria at spas. The division of the Ministry of Health and Social Apart from insured persons, the entire population Welfare which is in charge of training of medical and is entitled to free medical care at health centres, and health personnel determines the number of students specialized establishments provide care free of charge needed for medical studies and for training in other for children up to 16 years of age, for women during health subjects.The present tendency isto limit pregnancy and childbirth, for the chronic sick, for the number of students in the five faculties and to cases of infectious disease and venereal disease, and introduce improved methods of teaching, particularly for patients requiring the urgent attention of physi- by increasing practical training.On completion of cians or surgeons.The cost of preventive medical their studies, graduates do a one- or two -year intern- care is borne entirely by the State. ship in hospital before taking up their duties.Promo- There has been a noticeable improvement in the tion is based on seniority and competitive examination; state of health of the population in recent years, a doctor may become a junior physician after three which is reflected in the vital statistics for the past years of medical practice, a medical specialist after decade : five years, and a chief medical officer after ten years on 1947 1957 passing competitive examinations.The salaries of Birth rate 23.4 22.8 doctorsaredetermined by seniority,experience, Death rate 22.0 10.2 type of work and location; higher salaries are given to those working in the preventive services and in The infant mortality rate, which remained very high rural areas.Post -graduate specialization or refresher for a long time (between 170 and 190), and which courses (the duration of which varies according to accounted for more than 30 per cent. of all deaths, the branch of study) may be undertaken; in such is now declining at an increasing pace; in 1957 it was cases the institution in which the doctor is employed 81.0.The neonatal death rate dropped from 66 in bears the cost of his salary during the training period. 1948 to 27 in 1957; this mortality is reported to be There are at present 22 training schools for auxiliary due chiefly to acute diseases of the respiratory system. health personnel in Romania, which admit students The main causes of death, in order of importance, who have completed secondary school education; are : diseases of the cardiovascular system (excluding the number of students training as auxiliary health cerebral haemorrhage), diseases of the respiratory workers is still not considered sufficient. system, cancer, diseases of the digestive tract, tuber- The Ministry of Health and Social Welfare is at culosis, and accidents.Deaths from most causes have present drawing up a long -term plan for the develop- decreased during the past ten years, with the exception ment of the medical and health services, the training of deaths from diseases of the cardiovascular system of health personnel of all types, and the production (which had first place in 1954, with a rate of 270.2 of drugs and medical equipment. 294 FIRST REPORT ON THE WORLD HEALTH SITUATION
SPAIN
Spain lies in the south -west of Europe, surrounded on the There is a comprehensive range of social schemes, including south and east by the Mediterranean, on the west by Portugal those which come under the Labour Charter, whose object is and the Atlantic Ocean, and on the north by the Bay of Biscay to achieve better distribution and remuneration of workers and France, from which it is separated by the Pyrenees.The and to give holidays with pay and family allowances.In 1953, interior of the Iberian peninsula is an elevated tableland sur- 3 719 000 persons were covered for maternity and sickness rounded and traversed by mountain ranges.There is a great benefits, 8 708 000 for medical care, and over 5 million for variety of climate: equable on the Atlantic and northern coasts, accidents of employment.Under the family allowances scheme, with a fair rainfall well distributed through the year; arid in employers contribute 6 per cent. and employees 1 per cent. the interior with extremes of temperature, and on the Medi- of their earnings. terranean coasts warm summers and temperate winters.The area is 503 492 square kilometres. Health At the last census, in 1950, the population was 27 976 755, including that of the Balearic and Canary Islands. The estimated The origin of the Spanish health administration can population for 1955 was 29 089 142.Approximately 63 per be traced back to 1735, when a Supreme Health Junta cent. of the population are rural.Madrid, the capital, has a was formed with a view to preventing the importation population of 1 792 961.Agriculture employs about 5.3 million workers, industry 1.9 million, and commerce 700 000. of communicable diseases.Since then the health The provinces are made up of municipalities or boroughs, organization of the country has undergone numerous of which there were 9212 in 1950.All municipalities are auto- changes.Itits present form, the national health nomous in their own spheres and are directed by the Ayunta- administration -the Directorate -General of Health - miento.Municipal councils are elected by heads of families; the mayors and councillors are appointed by the Government. is under the Minister of the Interior.Closely asso- Each of the 50 provinces of Spain has its own Assembly, the ciated with the Directorate -General of Health are a DiputaciónProvincial,whichhas entire jurisdictionover national health council (a consultative body), the the province and is its sole administrator. School of Public Health (which is also part of the The country The economy of Spain is mainly agricultural. semi -officialconsultative is generally fertile and well adapted to agriculture and the pro- University), and various duction of fruits such as olives, oranges, lemons, almonds, bodies -the nationalPatronatos -in whichthe pomegranates,apricots and grapes.Agriculturalproducts Directorate -General of Health and official and semi- include wheat, barley, maize, oats, rice and high quality flax official consultative bodies as well as private agencies and hemp ; there is also a large production of wine.Agricultural are represented.So far only three national Patro- exports amount to some 60 per cent. of the foreign currency earnings.The mineral resources are variously exploited, and natos have been established; one for tuberculosis include coal, iron, tungsten, copper and lead.In 1954 the coal control, one for mental health and one for the care of mines produced 20 million tons of bituminous coal and nearly the physically handicapped. two million tons of anthracite.The production of Spanish and There are three other categories of central services Rif iron ore was 5 767 000 tons, and that of pyrites was nearly in the Directorate - General of Health -namely, inspec- twomillion.Thefishingindustryisimportant - mainly sardines, tunny -fish and cod.The principal manufactures are torates, institutions and sections.The inspectorates textiles,leather goods and ceramics and light engineering cover pharmacies, veterinary public health, training products.Spain imports cotton, jute, cereals and a considerable and research,provincial health and international amount of foodstuffs, machinery, motor cars and petroleum health.There are institutes for haematology, cancer products.The principal exports are iron and wolfram ores, cork, hides, perfume essences,fish,fruit,vegetables, wine, control and cardiology, and a hospital for communic- potash, olive oil, mercury and lead.Production is mainly able diseases.The sections deal with epidemiology in the hands of private enterprise. and statistics, maternal and child health, nutrition, Primary education is free, but compulsory attendance cannot malaria control, chronic diseases and geriatrics, com- be enforced because of the insufficient number of schools.The country is divided into 12 educational districts, centred round municable eye diseases, sanitary engineering, occupa- the universities.There are universities in Barcelona, Granada, tional health, mental health, hospitals and sanatoria, Madrid, Murcia, Oviedo, Salamanca, Santiago, Seville, Valencia, social welfare and health education. Valladolid, Saragossa, and in La Laguna in the Canaries. In each of the 50 provinces, the health organization In 1953 there were over 13 000 kilometres of broad gauge is under the supervision of a provincial director of railway lines and 5032 kilometres of narrow gauge lines.In the same year, 12 000 ocean -going vessels -with a tonnage of health, who is in charge of a provincial health institute about two million- entered the chief Spanish ports of Barcelona, located in the capital of the province, and also of a Seville, Malaga and Santander.In 1950, the total length of certain number of secondary and primary health roads was 111 000 kilometres, of which 82 000 kilometres were centres.The provincial health institutes are divided macadamized.Civil aviation is under the control of the Air Ministry ;severalinternalandinternationalservicesare into sections dealing with epidemiology, diagnostic operating. laboratory work, dermatology and social hygiene, EUROPEAN REGION 295 malaria control, mental health, mobile teams, haema- isolation of infectious cases or for surgical cases before tology, tuberculosis control, maternal and child health, they can be transferred to hospital.The various control of chronicdiseases,geriatrics,provincial categories of centres are connected by a transport specialists and veterinary public health.Some of these system which includes an adequate number of ambu- sections have dispensaries at their disposal, and sana- lances and other vehicles. toria and preventoria are available to the tuberculosis The Directorate -General of Health, through various sections. co- ordinating bodies, endeavours to ensure close co- Hospital care for assisted persons (that is, those not operation between its own services and the many included in compulsory health insurance)isthe private and semi -officialorganizations and other responsibility of the Diputaciones Provinciales, which governmental agencies engaged in health work. are alsoin charge of establishments for mental Reported death rates were 9.2 in 1954, 9.4 in 1955 care, maternity care, and homes for the destitute and and 9.8 in 1956; live birth rates were 20.0 in 1954, for old people.These services are autonomous, but 20.6 in 1955 and 20.7 in 1956; and infant mortality as far as health matters are concerned, they are under rates were 49.2 in 1954, 50.2 in 1955 and 45.5 in the supervision of the provincial director of health. 1956. The various branches of the social insurance admi- The most important communicable diseases notified nistration are under the Ministry of Labour and they during the period under review were measles, typhoid administer health insurance.The persons covered by fever, dysentery and diphtheria.The control of com- health insurance are also entitled to make free use of municable diseases is the responsibility of the relevant the preventive services offered by the State. central, provincial and local health services already The local services are administered by the Ayunta- described.Cases of malaria have decreased consider- mientos.Their chief duties are in connexion with ably, the latest reported figure (for 1957) being 420 as environmental sanitation, water supply, disposal of compared with 380 000 in 1943. excreta, food control, housing and town planning. Measures taken for maternal and child health care The larger municipalities have services covering both have reduced the infant mortality rates during the last social assistance and curative and preventive medical 20 years from 180 to 50 per 1000 live births and care, and many of them provide domiciliary care, maternal death rates from 4 to 0.4 per 1000 total births. medical care in case of accidents, and admittance to The maternal and child health services are staffed by municipal hospitals.They may also have laboratories 300 physicians,100 paediatric nurses,135 health and well -baby clinics.In a certain number of munici- educators and 50 auxiliary midwives. palities there are health centres administered by the There are ten medical faculties in Spain, and State; there are secondary centres in the larger towns, specializedpost -graduatetrainingisavailableto and primary centres of varying size in the smaller students who have completed their basic medical towns.There are at present 51 provincial health studies.Refresher courses are held each year under institutes(tertiaryhealth centres),257 secondary the aegis of a special organization -the Obra de Per - healthcentres,560 primaryhealthcentresand feccionamiento Sanitario de España. 1115 elementary primary health centres. The School of Public Health, which was founded in The minimum services provided by the secondary 1932, organizes various courses in hygiene, micro- health centres include maternal and child health, biology and public health for physicians, pharmacists control of tuberculosis and social diseases, odontology, and veterinarians. A diploma of public health is ophthalmology, and care of ear, nose and throat awarded to those who have followed the theoretical diseases.These centres are essentially for educational and practical training for several months and have and preventive purposes, and a great number of them passed a final examination.Holders of a diploma have rural maternity centres associated with them of public health may follow an additional, essentially which afford obstetrical care.The primary centres practical, training course organized by the School, work in close co- operation with the secondary centres, which leads to a further diploma qualifying its holder and although in principle they provide the same ser- for the position of public health officer.Courses for vices, they are smaller in size, have fewer staff and auxiliary health personnel are also organized by various afford no specialized services. special schools attached to the different faculties or The elementary primary centres include a residence under the Directorate - General of Health and affiliated for the physician, a dispensary and a ward for the with the School of Public Health. 296 FIRST REPORT ON THE WORLD HEALTH SITUATION
SWEDEN
Sweden occupies the eastern half of the Scandinavian peninsula Health and is bounded by Norway, Finland, the Gulf of Bothnia and the Baltic Sea.There are four main divisions: the northern The Royal Medical Board, subordinated to the mountain and lake region; the lowlands of central Sweden; Ministry of the Interior, is the supervisory authority the Smáland highlands in the south and south -east; and the for the health and sickness services.Mental hospitals, plaine of Skáne in the extreme south.The coasts are fringed certain teaching institutions and some laboratories with many islands.The climate is cold continental in the north and semi- continental in the south.The area is 449 000 aredirectlyresponsibletotheBoard.Teaching square kilometres. hospitals have a comparatively free status. A free The population was 7 041 829 at the 1950 census and was esti- central institution of great importance is the State mated to have risen to 7 341 122 at the end of 1956. Stockholm, Institute of Public Health, set up in 1938 for experi- the capital, has 794 113 inhabitants.The population is dis- mental and research work in social hygiene. tributed almost equally between rural and urban areas.The Lectures general educational level is very high. in hygiene are given to medical students and health Sweden isdivided into 28 constituencies.Each county inspectors, and courses are arranged for medical (Ian) has a county council (landsting), elected by universal officers.The National Public Health Nursing School adult suffrage and chiefly responsible for the administration ispart of the Institute.The Central Board for of the health service and vocational schools.Some of the large towns are independent of the landstings.Each rural district, Hospital Planning and Equipment is responsible for borough and town forms a commune or municipality, whose the medically and economically sound planning of council is also elected by universal adult suffrage.In 1954 hospitals, for the standardization of their equipment the number of communes was reduced from 2500 to 1037. and for the rationalization of their administration. For economic purposes the country may be divided into three districts: the northern forest area, the central area, which in- Responsibility for public health and medical care cludes mining, industrial and agricultural work as well as forestry, rests with (1) the State, (2) the county councils and and the southern area, which is mainly agricultural and industrial. the cities (Stockholm, Gothenburg, Malmo, Norr- Mining and forest products have been for centuries the koping, Hdlsingborg and Gavle), and (3) the municipa- chief industries of Sweden.The industries are spread fairly lities.Each county has a senior medical well over the country.Metal manufactures include several highly specialized products, ball- bearings, telephone supplies who isa civil servant and who supervises public and electrical machinery.Excellent porcelain and glass are health and medical care. also manufactured.Sweden is self -supporting in food produc- The county councils and the cities are responsible tion and has a certain amount of surplus. for most of the hospitals for somatic diseases.The Primary education is maintained by the State and by local taxation.It is compulsory and free, and illiteracy is so rare as State manages some teaching hospitals and certain to be a curiosity.Secondary education is highly developed. sanatoria.The mental hospitals are State -managed, There are three State universities -at Uppsala, Lund and with the exception of those in Stockholm, Gothenburg Gothenburg. 1There is also a State Faculty of Medicine, as and Malmo, where they are managed by the cities well as a number of other educational institutions at university with State grants. level, in Stockholm.The total number of students in 1956 was 23 817, including 2688 medical students. The county councils and cities further control the In 1956, the mercantile marine had 1608 vessels totalling district health service (district public health nurses), nearly 3 million gross tons (excluding fishing craft and other dispensary care for tuberculosis patients, maternal vessels under 20 tons).The largest ports are Gothenburg and and child health centres, delivery wards, the public Stockholm, both of which have a very large amount of foreign dental activities. shipping.At the end of 1956, there were 16 085 kilometres of service, and other Some towns railways, of which about 15 000 kilometres were State -owned. and districts have their own doctors and some have Thereisa national airline which operates services within small sick -care institutions. Sweden and to other parts of the world. Private practitioners play an important part in Sweden has a very comprehensive scheme of social benefits, medical care; many of them are employed in the financed by housing increments, insurance and taxes.Since the beginning of 1955, the whole population has been covered school or military health services in addition to their by a compulsory health insurance system which includes the practices.Certain voluntary associations, founda- cost of medical attendance, hospital treatment, travel to and tions and private persons also run sick -care institu- from doctors and hospitals, medicines free or at a reduced price, tions in such fields as tuberculosis and rehabilitation daily allowances and maternity benefits.In 1955,1 243 000 of the handicapped. persons were covered for unemployment. All activity of this kind is, however, supervised by the health authorities. Municipalities are responsible, through the local 1 In 1956 a new State University was founded in UmeS. health boards, for the public health in their areas. EUROPEAN REGION 297
Their activity is regulated by the Public Health Act with complete equipment or hospitals for convalescents of 1919, which requires the local health board, inter and chronic cases. alia,to provide for water and sewerage systems, After -care is provided by most hospitals in con- refuse disposal, and on the whole to maintain a high valescent departments, or inspecial convalescent level of hygiene.The local health boards also have homes.There are also a great number of privately important tasks in supervising the control of epidemic owned convalescent homes. diseases and tuberculosis and are responsible for An occupational care division was established by smallpox vaccination. the Royal Employment Board in 1952 to care for Other organizations which provide some form of those partially incapacitated for work.Sections for health service are the Swedish State Church, the occupational care exist in county employment offices, Royal Workers' Protection Board, the Royal Board and a great number of partially disabled persons of Education, the Swedish Red Cross, the Royal are placed in gainful work suited to their special Pensions Board, the Royal Social Board, the Royal conditions.Where special measures are required, Board of Roads and Waterways, the Swedish National occupational care generally takes the form of work Association against Tuberculosis, and the Associa- trials in work -clinics or training shops, vocational tion for Public Health. training and financial assistance for education or During the fiscal year 1954/55 the State costs for the starting of some kind of business. health and sick care were 332 million Swedish crowns The Public Dental Service came into being in 1939, (US $64 179 393), or 3.9 per cent. of the total State and is managed by the county councils and the six expenditure. free cities, with the approval of the Royal Medical The birth rate, which has been falling slightly Board.Each county is divided into dental districts since 1950, was 14.8 in 1956; the crude death rate with at least one dental clinic staffed by one or more was 9.6, and the infant mortality rate, which has dentists in each district. been falling very steadily, was 17.0. In 1938 a law granting State aid for maternity Various measures are taken by the Royal Medical and child welfare services came into force.The Board in health education, both for medical and county councils and the municipal councils in the public health personnel and for the general public. sixcitiesare responsible for the welfare services Pamphlets, posters and other material are issued on within their areas, and the Royal Medical Board epidemic diseases and general health education, vene- is the supervisory body.Maternity welfare centres real diseases, maternal and child welfare, food hygiene and child welfare centres are established in the six and dental hygiene.The Swedish Red Cross also plays cities,capital county towns and in small towns, an important part in health education of the public. wheretheyaresometimescombined.Inrural Tuberculosis dispensaries, are active throughout the districtsthe local medical officerattends to the country for the control of tuberculosis and for the maternity and child welfare work at maternity and out -patient care of tuberculous patients.Each county child welfare stations.In 1954 there were 84 mater- has one or more central dispensaries, the total for nity welfare centres, 178 child welfare centres and the country being 62.Under the central dispensaries 35 combined maternity and child welfare centres in there are district dispensaries, mainly carrying out towns.In the rural districts there were 553 stations field investigations and preventive measures.Mass and 805 branches.The whole population has access radiography has been performed on all conscripts to this service. since 1941, and the whole adult population of Sweden School health is the responsibility of the central was screened during the years 1946 -54. school authority of the State, and is the concern of The hospital care of somatic diseases rests with the Head Doctor for Schools, employed by this the county councils and the cities outside the county authority in full collaboration with the Royal Medical councils.As a rule, every county has a central Board.The service covers all the higher schools hospital, and in most counties there are also other throughout thecountry, and elementary schools hospitals with or without specialist departments for where local authorities have applied for it; at present internal medicine, surgery and radiology.There are it covers about 99 per cent. of children in elementary also cottage hospitals, of which the medical officer schools.Both school doctors and school nurses of the district is often in charge in addition to his must be employed in the schools if the work is to other functions.Special hospitals and cottage hos- be supported by State subsidy, and their work covers pitals have been established to deal with infectious a wide range of activities. diseases.The institutional treatmentof tubercu- The Workers' Protection Act of 1949 is the main losis is given in sanatoria, which are either hospitals statute governing the protection of workers, and 298 FIRST REPORT ON THE WORLD HEALTH SITUATION general prescriptions for the prevention of ill health communicable disease, and it rests with the doctor and accidents stipulate the hygienic and social mea- (usually the medical officer) and the local health sures to be taken.The Royal Workers' Protection board to make satisfactory arrangements for the care Board is the supervising authority for the observance and isolation of the patient in order to prevent the of thislegislation.The countryisdivided into spread of the disease.Except in certain cases the 11 districts, each with a factory inspector in charge patient must undergo treatment in a hospital.The and a staff consisting of a social inspector, a first local health board also carries out disinfection of district engineer, a district engineer and sub- inspec- the patient's house atpublic expense. A special tors.Special inspections are made in such spheres committee on communicable diseases is responsible asforestry,trafficover land, mining,explosives, for the organization of the care within the county, electricity and stowage. and the county medical officer may attend the meetings Mental care in Sweden is a State responsibility, of this committee.There were 42 hospitals for the although Stockholm, Gothenburg and Malm6 organize care of patients with communicable diseases at the their own mental health services.The State service end of 1956, with a total of 3488 beds. includes19 mental hospitals with their own ad- The duration of the medical course in Sweden is mittance areas, three secondary hospitals and five six and a half years, leading to the certificate of hospitalsformentaldefectives.Parliamenthas Licentiate in Medicine.The four medical schools passed a bill for the establishment of five new mental are government institutions, supported financially by hospitals, and three of them are under construction. the State and supervised by the Ministry of Educa- At least three more are planned, one of them for tion, but they are autonomous in such matters as mentaldefectives.Psychiatricwardshavebeen curriculum planning and organization of research. established in about 18 hospitals, and deal with light Post -graduate coursesare arranged by theState psychiatric cases, depressions and neuroses, psycho- Institute of Public Health and the Royal Board of somatic cases, alcoholics and others.The county Education. councils also have nursing homes for the chronic There are 28 basic nursing schools in Sweden, mentally sick who do not need hospital care. which give three years' training; in the last year it In conformity with the Epidemic Diseases Act is possible to specialize at other central schools in of 1919, a doctor must be called for in case of a psychiatric nursing, paediatric nursing and midwifery.
SWITZERLAND
Switzerland is the most moutainous country in Europe. The light industries.The chief imports are metals, cereals and other Alps take up part of its eastern frontier and the greater part foodstuffs, cotton and woollen goods, chemicals, machinery of the interior (61 per cent. of the total area), and the Jura moun- and motor vehicles. tains compose its western frontier (12 per cent. of the total area). Primary instruction is free and every district has primary The country is land -locked, with frontiers on France, Germany, and secondary schools.Switzerland has seven universities - Austria and Italy.Its total area is 41 288 square kilometres Basle, Zurich, Berne, Geneva, Lausanne, Fribourg and Neuchatel. and practically one -quarter of this is unproductive land. From Each of them has faculties of theology, law, philosophy, arts, the most eastern to the most western point the distance is science and, except for the last two, medicine.Medical quali- 348 kilometres.Switzerland has a population of 5 million, fications from any of the schools entitle the holder to practise of whom approximately 36.5 per cent. are urban and 63.5 per throughout Switzerland; the curriculum and the examinations cent. are rural.Berne is the capital, but the largest town is are prescribed by federal law. Zurich, with 400 000 inhabitants. A federal law of 1911 entitles all citizens to insurance against Four languages are spoken- German (72 per cent. of the illness,and more than3.8million peopleare members population), French (21 per cent.), Italian (6 per cent.) and of a social health insurance scheme.The bodies responsible Romanche (1 per cent.).The general educational level is high for this are the numerous mutual aid societies or cantonal or and illiteracy is unknown. The main occupations of the people communal health insurance funds.If these societiesfulfil are industry (823 000 workers),agriculture(255 000), and the minimum requirements fixed by federal law for health and commerce (253 000). accident insurance, they are subsidized by the Federal Govern- Agriculture is undertaken chiefly in the valleys and in the ment by means of an annual grant for each insured member, area between the Alps and the Jura, known as the " plateau ". this grant being higher for women than for men. An additional Wheat, oats, maize, barley, flax, hemp, tobacco, and many grant is paid for members living in mountainous areas.Al- fruits and vegetables are grown.Eighteen of the cantons are though there is a federal health and accident insurance law, it also wine- producing.Dairy farming and stock -raising, how- is for the cantons to decide whether health insurance should ever, are the principal agricultural activities.The most im- be compulsory, and, if so, up to what income; this power may portant industriesareengineering,clothing, watchmaking, be delegated to the communes. As a result, in some cantons chemical products, pharmaceuticals, wood -work and other as many as 96 per cent. of the population are insured, and in EUROPEAN REGION 299 others as few as 50 per cent.Since the universities are also supervision.The larger communes (towns) may or- cantonal institutions there is no federal law on nursing education ; ganize their health services on the same lines as those the cantons have therefore concluded an agreement whereby nurses' diplomas (issued by schools recognized by the Swiss of the cantons. Red Cross) are made valid in all areas upon ratification by the The total public health budget for the Federation, Director of Public Health of the canton concerned. cantons and communes in1955 was 382 400 000 Swiss francs (US $89 345 794) ;thatforold -age Health and public assistance was 403 900 000 Swiss francs (US $94 369 159),and132 100 000Swissfrancs Most public health matters are the responsibility (US $30 864 486) were spent on other social welfare of the cantons, and although a number of federal laws measures. on health have been promulgated their application is Vital statistics are drawn up by the Federal Statistical to a great extent entrusted to the cantons and com- Office with assistance from the cantonal statistical munes.Moreover, the encouragement and the sub- offices, which receive data from the cantonal civic status sidies given to private organizations tend still further offices. A census is taken every 10 years, the last to decentralize health organization, thus permitting being in 1950.In 1954 the birth rate was 17, the the great diversity of the population to be taken into death rate was 10, and the infant mortality rate was account. 27.2.Only about 0.5 per cent. of deaths remain At the national level, the responsibilities of the uncertified by a doctor, but in about 1.4 per cent. of Confederation include: prevention of communicable certified cases the cause of death isstated to be diseases at the frontiers of the country (frontier health unknown.Morbidity statistics cover notifiable com- services, medical examination of workers and refugees) municable diseases; there is no uniform pattern for and, in exceptional circumstances, within the country; hospital statistics on diseases and injuries treated, statistical services; legislation on health and accident but statistics on patients treated in mental hospitals, insurance and control of its application; prevention of in homes for psychiatric observation of children and accidents; inspection of working conditions in fac- in rehabilitation establishments for alcoholics are very tories; application, to a certain extent, of laws con- complete. cerning tuberculosis, narcotics, foodstuffs and other The total number of doctors in Switzerland in 1956 matters, and control of that application; establishment was 7233, of whom 4626 were general practitioners of advisory commissions; training of doctors, dentists, or specialists in private practice, hospital doctors pharmacists and veterinarians; payment of subsidies (not counting assistants and voluntary assistants), or for many activities of the cantons, communes or professors.This gives a ratio of one doctor per private voluntary organizations, such as the building 1082 persons. of infectious diseases hospitals and school medical Although most people are insured -for example, services.The administration and organization in- 3 800 000 participated in sickness funds in 1956 -no volved is carried out by the Federal Public Health doctor is employed as a medical practitioner by an Service of the Department of the Interior, in colla- insurance organization.All practise general or spe- boration with the Federal Offices of Social Insur- cialized medicine independently, with the exception of ance,Statistics and Industry, the Swiss Accident medicalofficersand those working full-timein Insurance Fund, the Army Health Service and various hospitals.There is a free choice of doctor, and an other organizations concerned with specific health approved schedule of charges determines the amount matters. to be paid to the doctor on the basis of services The cantons are responsible in particular for environ- actually rendered.In some mountain valleys the mental sanitation, cleanliness of houses, school, pro- doctor receives a fixed salary from the insurance fund, fessional and mental health services, establishment of the main reason being that he would not otherwise hospitals, etc., and control of sale of pharmaceutical have enough patients to earn his living.There are no preparations.These matters are also partly controlled health centres in the strict sense in Switzerland, and by the communes.Each canton has its public health the practitioners rely on their own consulting -rooms administration, with a chief of department and a staff and equipment.In many cases they also have public consisting usually of a doctor, a chemist, a veterinary functions -for example, as school medical inspectors surgeon, a pharmacist and a dentist -all working as or as members of the local health authorities prescribed cantonal chiefs of sections.There are also district by federal law for each commune or group of com- medical officers responsible for groups of communes. munes.In the larger cantons the medical officer of Each commune is legally bound to establish a local health is usually employed full-time, and there are also health authority and is in charge of school medical some other full -time medical officers of health and 300 FIRST REPORT ON THE WORLD HEALTH SITUATION school medical officers in some of the large towns. special hospitals, although every canton of any size Uninsured persons who cannot pay a doctor's fee may has one or more psychiatric hospitals.The nursing still choose their physician, and the fee will be paid staff of the psychiatric hospitals have different training by the commune of origin, or -in accordance with an from that of the general nurses.Many of these intercantonal arrangement (concordat) -by the com- hospitals have organized a family nursing system, mune in which they are living at the time.This rule whereby many of the patients live in specially selected applies to all public assistance, and many of the com- families.Such patients are, of course, under medical munes have set up old people's homes which are also supervision but are taken care of by the individual open to many Swiss who had never seen Switzerland families concerned. until the Second World War. Policlinics attached to the larger hospitals are be- With the exception of a few military sanatoria there coming more and more popular.These are centres are no federal hospitals.The most important hospitals where advice of a medical or social nature may be are public institutions run by the cantons, but there given free of charge in case of need, but they are now are also a certain number of municipal or city hospitals serving more and more as specialized centres with and many district establishments, especially in rural first -class equipment, which can also help the general areas.As a rule, every patient pays his own hospital practitioners in carrying out special examinations and bills; if he is not insured, the daily amount is fixed making diagnoses without it being necessary for the on the basis of an assessment, so that the poor pay patients to be admitted to hospital. A policlinic may less than the well- to -do.If the patient is insured, his also act as a medico -social dispensary for tuber- coverage will reimburse the hospital according to a culosis control work, and for such activities as maternal contract between the hospital and the health insurance and child health.Some of the smaller dispensaries fund.Nearly all hospitals have large annual deficits in rural areas are often run by a nurse or a social which are covered by State taxes.Very large sums worker.The policlinics are always operated under have been spent in recent years on the construction State auspices, but most of the dispensaries have been and modernization of hospitals. founded and are maintained by voluntary organiza- Federal old -age insurance is the main system for tions. The aim of the State is not to supplant voluntary providing economic assistance to the aged.It is a activities, but rather to give them support in providing general and compulsory form of national insurance, the necessary equipment and services. run by a special fund of the employers' organization Health education of the public is carried out through and supervised by the cantons and the federal author- the teaching of hygiene in all primary and secondary ities.In recent years many of the major hospitals schools, and during the compulsory military service have tended to become overloaded with the chronic period for men.It is also furthered by the Swiss sick, and special wards or units are being set up to Samaritans' Federation and by voluntary organiza- meet this difficulty.There are otherwise very few tions.
TURKEY
Turkey is situated at the north -eastern corner of the Mediter- was set up in Istanbul.In 1838, a Higher Council ranean with the Black Sea on its northern coast.To the north- of Health was established, followed in 1840 by the east and east are the Union of Soviet Socialist Republics and Iran, to the north -west, Greece and Bulgaria, and to the south- Civil Public Health Council.In1889 a central east and south, Iraq and Syria. Public Health Administration was founded, and in The area of Turkey is 776 980 square kilometres, and its popu- 1870 regulations came into force providing for public lation was 24 121 778 at the 1955 provisional census, giving a health services in the provinces.For a time, from density of 31 inhabitants per square kilometre.The population 1911 onwards, public health administration was under of the capital, Ankara, is 453 151, and that of Istanbul 1 214 616. The other three large towns are Izmir, with 286 310 inhabitants, the Ministry of the Interior, but in 1920 the Ministry Adana, with 172 465, and Bursa, with 131 336. of Health and Social Welfare came into being.The The chief agricultural products of Turkey are tobacco, olive present public health legislation dates from 1930, and oil, silk, cereals and fruitsThe subsoil is rich in coal, copper, governs, inter alla, the functions of the Ministry of chromium, antimony and manganese.There has been con- siderable development of industry in recent years. Health.The organization of the Ministry inits present form was laid down in a law promulgated in Health 1936. The modern organization of the health services The Ministry of Health and Social Welfare is the dates from 1827, when an academy of military medicine chief authority on health matters, although certain EUROPEAN REGION 301 public and private organizations (such as the army, with 20 or 25 beds, and offer curative services as well. the workers' insurance funds, and the State railways) Medical care is free of charge in both the in- patient have health institutions to meet their own needs. and out -patient departments of health centres and The Minister is in charge of the health services at the dispensaries.In hospitals itisalso free to those national and regional level, and is assisted by an who have not the means to pay, and includes drugs, Under -Secretary of State, who may act for him, and laboratory tests, and surgery. by an Assistant Under -Secretary of State. The following table shows the personnel strength Within the Ministry thereare departments of of the health services (and the increase in certain public health (responsible for social hygiene, control categories) during the years 1954, 1955 and 1956: of communicable diseases, and international health Category 1954 1955 1956 relations);socialwelfare(curativemedicine and Physicians 3045 3111 3386 medical care;construction, equipment and main- Dentists 41 44 48 tenanceof healthestablishments);personnel(in Pharmacists 79 69 60 charge of all health personnel working in Turkey); Sanitary inspectors . . 2903 2733 2887 Nurses 889 928 984 sanitary control of ports and frontiers; pharmacies Midwives 485 471 459 and pharmaceutical products; health education and Assistant nurses 146 244 295 medical statistics; and malaria control.There is also Rural midwives 960 1003 1088 a board of public health inspectors, a board of consultation and enquiry, a legal office, and divisions The distribution of medical and health personnel of accounts, archives, and supplies and equipment. throughout the country is somewhat uneven, since The Higher Council of Health, consisting of nine many prefer to live and work in towns rather than in members chosen from among leading experts in health rural areas. matters, meets for ten days three times a year. Very thorough statistical surveys, which have been At the provincial and local level, health administra- carried out since 1951 in the district of Beypazari, tion is under the authority of the provincial governor, in the Ankara area, show the following trends in advised by a Director of Health in accordance with vital statistics :birth rate, 38.8 in 1951, 36.6 in 1953, policy instructions received from the Ministry of and 34.5 in 1955; death rate, 16.8 in 1951, 13.3 in Health; at the district level, the governor is represented 1953, and 11.7 in 1955; infant mortality rate, 124.3 by the district civil authority, and the Director of in 1951, 158.4 in 1953, and 117.3 in 1955. Health by a district medical officer, who in turn The main health problems in Turkey at the present advises the civil authority on public health matters time are tuberculosis, endemic infectiousdiseases and is responsible for preventive and curative services, and malaria; other questions of urgent concern to the as well as for forensic medicine, in his respective healthauthoritiesare the extension of maternal district.He isassisted by public health nurses, andchildhealthservices,thestrengtheningof sanitary inspectors, and urban and rural midwives. nursing services, and a more complete coverage of At the municipal level, health administration is con- the population by the health and social welfare cerned chiefly with environmental services. services. The percentage of the national budget allocated to The first quarantine administration was established health during the period under review was 5.6 in 1954 in Turkey in 1840 and was an international organiza- and 5.1 in 1955 and 1956.At the provincial level, tion with the principal task of protecting Europe the percentages of the provincial budget devoted to against diseases coming from the East; it was abolished health services were 2.48, 2.31, and 2.15, and at by the Treaty of Lausanne and replaced by the Depart- the municipal level, 21.27, 20.01, and 23.86 respectively. ment for Sanitary Control of Ports and Frontiers. In 1956 there were 95 general hospitals in Turkey, This Department is now in charge of nine centres with a total capacity of 15 195 beds, and 207 health and 26 offices, as well as two bacteriological labora- centres with a total of 2452 beds.These health tories,three quarantine administrations, and two centres, which have been developed since 1937 chiefly medical posts at the airports of Istanbul and Ankara. to meet the needs of the rural population, are among The control of infectious diseases within the country the most important elements in the country's health really began in 1914, but was made an actual legal services.They are located in the chief towns of undertaking with the passing of the public health districts, and the present programme aims at the law of 1930.This law includes the provision that establishment of a health centre in every district; all infectious and epidemic diseases which come to their main emphasis is on preventive medicine, but the knowledge of any member of the medical profes- they may be provided - according to local needs - sion must be reported to the medical officer of health, 302 FIRST REPORT ON THE WORLD HEALTH SITUATION who will immediately take appropriate measures, in the malarious areas: from 26.0 in 1946 and 7.0 in which full co- operation must be forthcoming from in 1950, it fell to 0.7 in 1955. all the administrative units concerned.The necessary In 1952, a Maternal and Child Health Section was supplies of vaccine and serum are provided by the established in the Ministry of Health and Social Refik Saydam Central Institute of Hygiene in Ankara. Welfare, and since then services for mothers and Smallpox vaccination is compulsory. children throughout the country have been con- Organized measures for tuberculosis control were siderably strengthened. A maternal and child health first taken in 1924, when a sanatorium with 50 beds demonstration and training centre was opened in was opened on the Island of Heybeliada in the Sea Ankara in 1954, similar centres were set up at Izmir of Marmora. The progress of the campaign since and Yenimahalle in 1955, and a fourth at Bursa in that time is illustrated by the fact that in 1956 there 1957.Extension of services to rural areas began were 52 tuberculosis control dispensaries maintained in 1956 with the formation in several provinces of by the Government, and 66 other institutions caring mobile teams, based on local maternity clinics, which for tuberculosis patients under the auspices of the visit villages in their areas.Furthermore, a training Ministry, providing a total of 7777 beds.Since 1952 scheme for rural midwives is being planned; the a large -scale BCG vaccination campaign has been in course will last 18 months and will consist of six progress; mobile teams have carried out tuberculin - months' theoretical training,six months' practical testing of 13 500 000 persons (more than half the work, and six months' probation.On completion population), of whom 5 300 000 have received BCG of their training the rural midwives will be posted vaccination.These measures have undoubtedly con- to village health units, although they will continue tributed to the decline in the death rate from tuber- to be under the administrative and technical super- culosis, which fell from 150 per 100 000 in 1950, vision of the district health centres.The last six to 78 in 1955. months of training will be spent in a pilot area in the Syphilis was introduced into Turkey some seventy district of Ankara (Kizilcahamam), which has 50 000 years ago, and became a serious public health problem inhabitants and 103 villages.Facilities for maternal in certain areas.With the help of legislation a and child care in hospitals and clinics have also in- systematic control programme was built up, and free creased in recent years.Whereas in 1926 there were treatment of this disease is now given either in special only two government maternity clinics, with a total venereal disease control clinics or - where these do of 25 beds, by 1956 there were 18 clinics, with 1716 not exist - by the local medical officer of health. beds.Furthermore, priority is given to maternity In 1950 there were 32 special clinics and 68 treatment cases in health centres and hospitals; 57 general stations in areas where the disease was widespread; hospitals have special departments for gynaecology by 1955 there were 33 clinics and 160 treatment and obstetrics.Out -patientservicesincludepre- stations.During the same period, as a result of these marital medical examination, pre -natal and post- active control measures, the number of cases of natal care of mothers, infant welfare clinics, vaccina- syphilis fell from 104 491 to 61000. tion of infants and children, and domiciliary mid- Trachoma also became a menace only in compara- wifery and infant care services. tively recent years, and a control programme was The Ministry of Education is responsible for the launched in 1925.In 1950 there were 40 trachoma organization of school healthservices, but close control clinics and 111 rural treatment stations, where- liaison is maintained with the Ministry of Health as there are now 50 clinics and 229 stations.In 1951, and with non -governmentalorganizationswhich 27.3 per cent. of persons attending for consultation participate in this work.Most schools have fully at eye clinics were found to have trachoma, while equipped medical clinics, and all boarding -schools in 1955 this percentage had dropped to 17.3. have a sick -room where children can be accom- Malaria had for long ravaged Turkey, and a modated for short periods in case of illness.School campaign for its control was started in 1924. A doctors carry out regular medical examination of Malaria Institute was founded at Adana in 1926, schoolchildren, and owing to the shortage of qualified where from 1928 onwards courses have been organ- school nurses, they are often assisted in non -medical ized to train health personnel in the principles of malaria aspects of the work by the school teaching staff. control.Control measures have been intensified in The service includes dental examination, and tuber- recent years, including the residual spraying pro- culin- testing and BCG vaccination are carried out by gramme; in 1955, 595 tons of DDT were used, com- the National League against Tuberculosis on behalf of pared with 109 tons in 1950.The results of the cam- the school medical service.Records of each child's paign are illustrated by the decreasing spleen rate health are kept and sent annually to the provincial EUROPEAN REGION 303
Education Department; the individual files are usually medical examination of their workers on recruitment transferred with the children from one school to and periodically during their employment, as well another and follow them throughout their scholastic as in- patient and out -patient care and free distribution career.Recommendations are also sent to parents of medicaments to employees and theirfamilies. if any special care or treatment of their children is Many large undertakings have built their own hos- considered necessary.Itisplanned inthe near pitals, and many provide free canteen meals during future toestablish school medical centresinall working hours.Some factories are setting up safety provinces and townships with a population of more committees in the workshops, on which both the than 10 000. employers and the workers are represented. There are no organized preventive mental health There are no special institutions for the care of the services as such in Turkey, although the maternal chronic sick or the aged, but there are hospices where and child health and school health services include these people are housed and fed.There are at present in their functions the promotion of mental health 13 homes for the poor in the country. in the groups with which they deal, and the neuro- A special subcommittee has been formed to under- psychiatricservicesin the general hospitalsalso take research on nutrition subjects, and a number of make their contribution to this end.For mental nutrition surveys are being planned.Several pro- diseases there are three psychiatric hospitals in the vinces have also started training courses for food country with a total of 3675 beds. economists. The Department of Health Education and Medical Food control (including meat and milk) and ins- Statistics of the Ministry is responsible for health pection of public health equipment and supplies are education of the public, which is organized by means undertaken by the State, through the local municipal of leaflets, posters, films, broadcast talks, lectures authorities; in places where there are no municipal and health museums.There are seven health museums authorities, the Ministry of Health provides an inspec- in the country, which were visited by 532 043 persons tion service.Control of pharmaceutical products is in1956.An Institute for Health Education has undertaken by the Department of Pharmacies and recently been set up at the School of Hygiene, where Pharmaceutical Products of the Ministry of Health. health education material is prepared, research is The Central Hygiene Instituteisthe country's carried out, and training courses for health educators main public health laboratory; it serves also as a are given.Many voluntary organizations also take reference laboratory and forthe preparation of part in health education, and in 1955 a Turkish vaccines and sera of all kinds.In the larger towns, National Committee for Health Education of the municipal public health laboratories provide control Public was formed in order to co- ordinate their work services, and elsewhere this work is carried out by and ensure the orderly development of health educa- hospital laboratories. tion activities throughout the country.Apart from There are three faculties of medicine in Turkey - at representatives of the government departments con- Istanbul, Ankara and Izmir.The last mentioned cerned, members of this committee include representa- was founded in 1955 and isstill in the process of tives of medical faculties, the School of Hygiene, the being organized.At Istanbul, 7706 medical students Red Crescent Association, theSociety for Child graduated between 1923 and 1955 (498 of them Welfare, the National League against Tuberculosis, women), and at Ankara there were 1247 graduates and other voluntary bodies concerned with health (119 of them women) between 1945 and 1955. Istanbul education. also has faculties of dentistry and pharmacy.Post- The problems of health and safety of workers have graduate courses of two or three months' duration been aggravated by the rapid pace of industrialization are organized each year for doctors at the School in Turkey in recent years. A considerable amount of Hygiene in Ankara, on a wide variety of medical of legislation has been passed to provide for industrial and health subjects.Training of auxiliary health health services and safety of workers in industry, personnel is carried out in special schools organized and the Ministry of Labour and the Ministry of by the Ministry of Health, the Medical Faculty of Health and Social Welfare are jointly responsible Istanbul,the Red Crescent Association, and the for ensuring that it is enforced.There are not at National League against Tuberculosis in Istanbul; present enough specialized staff to provide adequate there are courses for nurses, midwives, rural mid- supervision inthisconnexion, but measures are wives,laboratorytechnicians,sanitaryinspectors being taken totrain personnel.Apart from the and social welfare workers.The following table requirements laid down by law, many large industrial shows how these training programmes have developed concerns organize their own health services, including during the period under review: 304 FIRST REPORT ON THE WORLD HEALTH SITUATION
Number Category of staff of schools 1954 1955 1956 are 170 students following the courses in question. Nurses, midwives and labo- There are also 18 -month in- service training courses ratory technicians: in hospitals for auxiliary nurses; candidates must have Number of students . 7 295 354 372 completed their primary education and be over Number of graduates . 71 109 117 18 years of age. Rural midwives: The central environmental sanitation serviceis Number of students . 10 100 250 348 staffed by a specialized sanitary engineer, an engineer, Number of graduates . 100 250 348 a chemist and a physician.At the provincial level Sanitary inspectors: thepublichealthdepartmentsareresponsible Number of students . 1 300 300 400 Number of graduates . 68 61 138 for environmental sanitation.Chlorinated drinking - water, which is sometimes also filtered, is supplied to Post -graduate courses are held for nursing adminis- about 75 per cent. of the population.Sewage dis- trators, nurse tutors, and public health nurses for posal is by drainage to the sea or into water -courses maternal and child health centres; some 15 -20 staff or sewage farms.Measures taken against air pollu- are trained in each of these categories annually. tion include the fitting of ventilation systems in many Post -graduate training of rural midwives was started establishments, such as factories, workshops, cinemas, in 1956, in connexion with the rural health programme theatres and public baths. Where necessary, action is already mentioned, to prepare these workers for also taken to protect those exposed to the risk of practice in the districts at village health units; there radiation in places of work.
UNION OF SOVIET SOCIALIST REPUBLICS
The Union of Soviet Socialist Republics extends over part of The remarkable successes in the development of industry Eastern Europe and Northern and Central Asia.It is bounded achieved during the years of the five -year plans have led to a on the north -west by Norway, Finland and the Baltic; on the noteworthy increase in the number of workers and employees, west by Poland and Czechoslovakia, and on the south -west by who, together with their families, made up 58.3 per cent. of the Romania.To the south and south -eastlie Turkey, Iran, whole population of the USSR in 1955.In 1957 there were Afghanistan, China, Mongolia and the Korean People's Demo- 53.1 million workers and employees in the Soviet Union, as cratic Republic; in the north is the White Sea and the Arctic against 12.9 million in 1913. Ocean and in the east the Pacific Ocean.This vast territory, The USSR comprises 15 constituent Soviet Socialist Republics: which includes part of the Arctic region, is extremely varied in theRussianSocialistFederalSovietRepublic (RSFSR) geographical character.There are mountains in the Caucasus, which has the largest area and population (108 400 000), on the borders with Iran, China and Mongolia, and in north -east the Ukraine, Byelorussia, Uzbekistan, Kazakhstan, Georgia, Siberia.The comparatively low Ural Mountains form the Azerbaizhan, Lithuania, Moldavia, Latvia,Kirghizia, Tad- conventional dividing line between the European and Asiatic zhikistan, Armenia, Turkmenistan, Estonia; two of them parts of the USSR. The rest of the territory is mainly a wide - Byelorussia and the Ukraine -are separate Member States plain.In the European part the main rivers flow into the Black of WHO. Sea and the land- locked Caspian; in Siberia, they flow into the The most remarkable feature of the Soviet economy has been Arctic Ocean.Access to world sea routes is relatively restricted the transformation of what was primarily an agricultural country in comparison with the great size of the territory. into one of the foremost industrial nations of the world in the The climate in the greater part of the USSR is temperate, cold, course of the five successive five -year plans.Compared with continental, or, in the north, sub -polar.In the small areas of 1913, gross industrial output had increased 33 -fold by 1957, the desert the climate is hot.There is a Mediterranean climate in the production of the machine -tool and metal -working industries Crimea and along the Caucasian coast of the Black Sea, havingincreased200 -fold,and electric power production and a warm, continental climate in the regions bordering on 108 -fold. Afghanistan. Industry in the USSR is based on State ownership and control, The total area is 22 403 000 square kilometres.The last census and is administered by the responsible Ministries, State Com- was taken in 1939, and the population of the country at that mittees and National Economic Councils in the economic time was 170 600 000.The figure for 1956 was estimated districts. at 200 200 000; the next census will take place in 1959. There is universal education for a period of ten years free of There are a great number of ethnic groups in the USSR, which charge, and a State system of scholarships in special establish- can be subdivided into four broad groups: Slays (the largest), ments of higher and secondary education for students who have Mongols, Finns, and Ural -Altaians. been successful in their studies.The largest university of the By 1939 it was estimated that illiteracy had been reduced to Soviet Union is in Moscow.According to the most recent data below 10 per cent. among males over nine years of age, and to (1956 -57) there are, all in all, 767 institutions of higher learning less than 28 per cent. among females of the same age.This throughout the country. In the academic year 1957 -58, more figure has been much lowered in recent years and illiteracy has than 50 million people in the USSR were receiving some form now almost completely disappeared from the USSR. of education.There are a great number of technical, scientific EUROPEAN REGION 305 research, and art institutions.The main research and scientific nistration of the health services are assigned to the centre is the Academy of Sciences of the USSR. Chief Physician of therayon,who isat the same Moscow and Leningrad are the main focal railway centres. The central and southern parts of the country are well served timethe Chief Physician of therayonhospital. by railway lines running from north to south and from west to The Sanitation and Epidemiological Centre in such east, but in the eastern part of the USSR, in the Volga region and rayons isthe Sanitation and Epidemiological Depart- in Siberia, there are lines running from west to east connecting ment of therayonhospital. Europe with Asia, but a lack of lines running north to south. In the localities public health is administered by This deficiency is, however, now being met by the construction of new lines. the localSoviets of Working People's Deputies; The main ports are situated on the shores of the Baltic, Black these are responsible for medical aid and maternity and Azov seas.Except for Murmansk, the northern ports, centres, which are financed out of the rural budget, which include Leningrad and Archangel, are not navigable in and also for maternity homes and crèches attached winter.Several new ports have been built on the Arctic Ocean to the collective farms.They also undertake measures which are open for navigationallthrough the summer. Vladivostok, the largest port in the Soviet Far East, is navigable for preventing infectious diseases and for health throughout the year, icebreakers being used to keep it open education of the public.The recent trend in the in winter. USSR has been towards increasing the powers and There is an extensive system of canals connecting the largest duties of local bodies, and the regional officers have rivers of European USSR and providing direct communication between the White, Baltic, Black and Caspian seas.Civil become more independent of headquarters' control. aviation is very well developed. Although public health and medical care are free There is a very comprehensive and complete system of social of charge to all, some charges are made for drugs. security covering in principle the whole population. During the period 1954 -56 there was an increase The continuing growth of housing construction is worthy of note.In 1954, the total area of dwelling houses constructed in State funds allocated to social security services was 32.5 million square metres; in 1955, 33.4 million; in 1956, and benefits for workers and employees, for old -age 36 million; and in 1957, 48.4 million. and invalid pensions, for large families and self - supporting mothers, for travel to and stay at spas Health and rest homes either free or at reduced prices, for The development of public health work in the USSR the provision of medical assistance, for education, has been based on a set of established principles science and culture.These allocations amounted to whereby the State, through concerted efforts of co- 147 000 million roubles (US $36 750 000 000) in 1954, ordination and planning in education, research and 154 000 million (US $38 500 000 000) in 1955, and practice, and with the active participation of the 169 000 million (US $42 250 000 000) in 1956. population, provides a system of integrated curative The successes achieved in the economic and social and preventive services for the protection and improve- spheres have led to the enactment during the period ment of the health of the people in the Union. under review of a series of legislative measures which The administration of the health services in the are of importance for the maintenance and develop- USSR is on four different levels.At the Soviet ment of public health.Apart from the laws relating Union level there is a Ministry of Health, which is to pensions, special mention must be made of the an integral part of the Council of Ministers.The decisions (1956) concerning the shortening of the Union Ministry of Health isresponsible for the working day on days preceding leave and holidays, planning and co- ordination of health programmes the Decree (1955) of the Praesidium of the Supreme and services for the entire Union, for setting up Soviet to repeal the prohibition of interruption of standards for various health establishments, and for pregnancy, and the Decree (1956) to increase the approval of health budgets and plans submitted by duration of maternity leave. the Republics.In each of the 15 Republics there The general death rate has fallen from 18.3 in is a Republic Ministry of Health dealing with the 1940 to 7.5 in 1956. administration of health services within its jurisdic- The joint efforts of scientific workers and field tion.At the district level of each Republic there workers have contributed to the successful control is a district health service and at the local level there of infectiousdiseases.Examples of thisare the isa regionalhealthservice.The local (rayon) eradication of relapsing fever and Grigoriev -Shiga health services consist of a combinedrayonhospital dysentery, and a sharp fall in the morbidity due (that is, with polyclinic attached), and a Sanitation to Flexner -Sonne dysentery, brucellosis and infec- and Epidemiological Centre under the authority of tious diseases of children (such asscarlet fever, therayonHealth Departmentofthe Executive whooping -cough and measles).The control of mal- Committee of Working People's Deputies.In many aria is a spectacular example; the morbidity of malaria rural areas all the duties connected with the admi- in 1956 was less than one -sixtieth of that in 1950, 306 FIRST REPORT ON THE WORLD HEALTH SITUATION and only 13 000 cases of malaria were registered in during the field work seasons and in 1956 the number 1956 throughout the whole country.In recent years of beds in this type of crèche amounted to 2 386 800. there has been a continuous decline in the mor- During recent years there has also been an increase bidity and mortality due to tuberculosis; between in the number of children's hospitals and children's 1950 and 1956 the tuberculosis morbidity in towns departmentsingeneralhospitals;by1956they decreased by 41 per cent.By the end of 1956 the comprised 192 478 beds.There were 1095 children's total number of tuberculosiscontrolinstitutions, sanatoria with 106 000 beds in the USSR in 1955. including 1164 tuberculosis dispensaries, had reached For children of school age with incipient and quiescent 5300, and in addition there were 2102 sanatoria, forms of tuberculosis, forest schools have been opened with 289 000 beds, and 900 rest homes, with 159 000 in which they received sanatorium care, treatment and beds.There were also 5451 venereological institu- schooling at the same time. tions throughout the Union. The system of industrial medical services has been For general medical care there is a network of supplemented by new medico -sanitary units, which hospitals and out -patient establishments -such as unite all the medical establishments (hospitals, poly- polyclinics, both independent and attached to hos- clinics, medical posts and night sanatoria) providing pitals, maternal and child health consultation centres, services for workers and employees of industrial medical posts, medico -sanitary units in industrial undertakings.In 1951 there were 725 of these units, undertakings, and feldsher- midwife posts in the rural 575 of which included in- patient accommodation areas.In 1956 there was a total of 25 178 hospitals, with a total of 47 527 beds; by 1956 there were with1 360 800beds,and33 854establishments 964 units, 829 of them with in- patient accommoda- providing out -patientservices;allthese establish- tion and a total bed capacity of 84 970. ments also provide domiciliary medical care and Side by side with the medico -sanitary units, the first -aid. medical and health posts under the supervision of In 1956, there were also 1368 oncological institu- physicians and feldshers play an important part in tions, 2327 psycho -neurological institutions, 1191 phy- providing medical services for workers.The number siotherapy dispensaries, and 1731 first -aid stations. of medical posts under the direction of physicians The maternal and child health services at the end increased from 6037 in 1955 to 6415 in 1956; the of 1956 included 7156 women's consultation centres, number of feldsher posts increased in the same period 142 911maternity beds in maternity homes and from 12 494 to 13 564. hospitals and 29 660 beds in maternity homes attached Night sanatoria established in association with tocollectivefarmsandfeldsher- midwifeposts. industrial undertakings (of which there were 585 with Practically all pregnant women in the country received 20 700 beds in 1956) constitute an important form services from women's consultation centres in 1956, of medical organization, which makes it possible to and all deliveries in the cities were carried out in carry out the planned improvement of the health of maternity homes or hospitals.In rural areas almost specific groups of workers.During recent years there all deliveries were conducted by trained personnel. has been a considerable extension, especially in the More than 60 per cent. of all deliveries in the cities chemical and coal- mining industries, of " photaria " and 40 per cent. in rural areas were conducted by the andinhalatoria,whichhavehadanoticeable " painless labour " method based on Pavlov's physio- effect on the prevention of a number of diseases. logical doctrine. The training of medical staff occupies a prominent Children from birth to the age of 14 years are placeinplanning.ThefirstRussian university, regularlysupervised and givenmedical care by which included a medical faculty, was founded in children's consultation centres and polyclinics, the Moscow in1755.Under theSovietregime,a network of which has been further extended during thoroughly planned reform of medical education was the past three years.Between 1955 and 1956 alone carriedout.Thecurriculumforundergraduate their number rose from 7037 to 7125.In 1956, medical education had to be revised in order to 80.6 per cent. of infants in towns were undergoing combine curative with preventive medicine and thus routine monthly medical examinations; of the infants prepare graduates to organize integrated health ser- examined, 85.3 per cent. came under medical sur- vices for the people. A large number of depart- veillance during the first month of life. ments were set up for teaching the preventive branches An extensive network of children's crèches has of medicine, including chairs forsocial hygiene, been developed.In 1955 there were 851 000 beds school hygiene and occupational health.In 1930 in permanent crèches, and in 1956 there were 904 300. the medical faculties were separated from the uni- On collective farms, seasonal crèches areset up versities and transformed into independent medical EUROPEAN REGION 307 institutes under the direction of the Ministry of Leadershipin medical researchrestswith the Health. A six -year course is laid down for medical Academy of Medical Sciences, and there are also students and a five -year course for pharmacy students. 268otherscientificinstitutes;altogether28 663 The first three years of the medical course are devoted investigatorsarecarrying out research work in to basic and pre -clinical sciences and an introduc- various medical and health fields. tion to medicine and surgery.The last three years, The most important condition for ensuring unity including a year of supervised practical work, contain of science and practice, and for the successful solution subjects required for three separate fields of activity: of public health problems, was the carrying -out of paediatrics, curative medicine and public health. A scientific research and practical measures in accord- four -year training is given for full nursing qualifica- ance with a concerted plan adopted by the Praesi- tion, and two years for feldshers and midwives. dium of the Academy of Medical Sciences and the In 1956 there were 79 medical schools and 603 schools Scientific Council of the Ministry of Health.This for the training of auxiliary health personnel, with plan covered a number of fundamental problems, a total of 152 767 medical students and 194 868 including community health, nutrition, school health, students in auxiliary health subjects.In 1956 the occupational health and physiology of work, pre- total number of health workers in the civil services vention of occupational diseases, control of infec- of the entire Soviet Union was 2 736 000, including tious and parasitic diseases, cardiovascular diseases, 329 400 physicians, 25 000 dentists and about 1 000 000 rheumatism, malignant tumours, and diseasesof auxiliary health workers. women and of the newborn.
UNITED KINGDOM OF GREAT BRITAIN AND NORTHERN IRELAND
The British Isles lie off the north -west coast of Europe, only in certain cases, parish councils.The corresponding authorities about 34 kilometres from the continent at the nearest point. in Scotland are county and large burgh councils, town and These islands, including Scotland in the north, extend from district councils, and, in Northern Ireland, borough councils, 40° to 50° north.Wales and the north and west of Scotland are municipal town councils and urban and rural district councils. largely mountainous, and the Pennine Range runs like a back- In England and Wales there are 83 county boroughs, 309 bo- bone through north and central England.The west coast of roughs and 1047 districts; in Scotland, 24 cities and large burghs, Scotland is studded with many islands. 173 town councils and 199 districts.Northern Ireland has Throughout the area the west coast is warmer than the east, two county boroughs, eight boroughs and municipalities and and has a greater rainfall.The total land area of the United 60 districts.In general, the members of local authorities are Kingdom is 244 015 square kilometres.The population at the directly elected by the citizens; councillors are elected for a 1951 census was 50 225 224, with a density of 206 per square period of three years.The County of London has 28 metro- kilometre.Approximatefiguresare:England and Wales, politan boroughs, which have important concurrent powers with 44 000 000 inhabitants;Scotland,5 100 000; and Northern the county. Ireland, 1 400 000.Over 80 per cent. are urban dwellers, and The economy of the United Kingdom is largely industrial but the population of Greater London in 1951 was 8 348 123.There agriculture and fisheries supply a great deal of food and even are no ethnic groups as such.The population is mainly of mixed some exports.In 1953,1 000 000 tons of fish were landed, Teutonic and Celtic stock, the Celtic type being most prevalent valued at £41 000 000 (US $114 800 000).The output of coal in Wales and the north -west of Scotland. in the same year was over 223 000 000 tons, of which 13 500 000 The general educational level is high with a literacy figure of tons were exported.The United Kingdom is widely industria- over 95 per cent. lized, and nearly every kind of industry is represented.The One of the characteristic features of English public life is the principal imports are foodstuffs, wood, wool and cotton, petro- very large number of voluntary organizations.It is difficult to leum and its by- products, chemicals and paper.The principal make a selection, but perhaps the WVS (Women's Voluntary exports are chemicals, wool and cotton goods, manufactures of Service) and the WRI (Women's Rural Institutes) are the most many kinds, road vehicles, aircraft and ships.Production is versatile.These organizations contribute extensively to the very largely in private hands, but railways, coal mines and health services, especially at the local level. electric power are nationalized. The ministers usually in the cabinet include those for Housing Primary and secondary school education are free, and school and Local Government; Education; Pensions and National attendance is compulsory to the age of 15.There are also a Insurance; Agriculture, Fisheries, and Food; and Labour and number of private boarding -schools, known as "public" schools, National Service.The Minister of Health is not a member of which are independent of the State system, as well as some 5000 the cabinet but is " of cabinet rank ". private schools.All schools, however, are inspected by the The chief local authorities are the councils of counties and Ministry of Education and may be closed if found to be ineffi- county boroughs (i.e., the larger cities).The other local authori- cient.There are 16 degree -granting universities in England; one ties are borough councils, urban and rural district councils, and in Wales; four in Scotland, and one in Northern Ireland.All 308 FIRST REPORT ON THE WORLD HEALTH SITUATION theseinstitutions are self -governing and they receivetheir for the administration of the general practitioner grants from the Treasury, through a special university grants service.Each has 25 members, 12 appointed by committee, and not from the Ministry of Education. There is an extensive network of railways, but only a very the local doctors, dentists and pharmacists, eight by small proportion of the lines have been electrified so far - the local health authority and the remaining five by the namely, 1500 kilometres out of 31000.There are approximately Minister of Health. 300 000 kilometres of public roads of which only 14 000 kilo- The health services of Scotland are largely on metres are trunk roads. An additional 31 000 are classified as the same lines as those in England but under different class 1. In July 1954 Lloyd's Register showed 3828 steamships of over statutoryauthority.The Secretary of Statefor 11 000 000 gross tonnage, and 1912 motor vessels totalling nearly Scotland is responsible to Parliament for the health 8 000 000 tons.This figure excludes ships of less than 100 tons. service.The local authorities are the councils of In 1954 a tonnage of over 115 000 000 was cleared from the counties and large burghs.The county councils main ports of the United Kingdom. There are two main State -owned airlines and a number of are responsible for the major public health services private charter companies. in the small towns, which in turn undertake local Social security schemes cover the whole population.After sanitary and hygiene services.General practitioner the Second World War the partial schemes which had previously services are administered by executive councils, and been in force were replaced by a comprehensive system of natio- nal insurance and industrial injuries insurance, with national the responsibility for hospitalservicesrestswith assistance and family allowances in the background.The Na- theSecretary of State.The main differencein tional Health Scheme provides medical care, including hospital Scotland is that teaching hospitals are included in care, for all persons, whether they are insured or not. the regional services and have no separate boards of governors.There isalso a medical education Health committee in each region.Responsibility for local In England and Wales the Ministry of Health is health services,e.g., maternity and child welfare, under a Minister, who has a Parliamentary Secretary. home nursing, etc., rests with the major local autho- In Scotland the Department of Health is under the rities - thatis, the county councils and the towns Secretary of State,and these two ministersare councilsof largeburghs.Healthcentres come responsible to the Imperial Parliament.In Northern immediately under the control of the Secretary of Ireland the Minister of Health and Local Govern- State and not the local authorities. ment is responsible to his Parliament.The Welsh The health services of Northern Ireland follow the Board of Health is in effect a special department same general lines as those of England and Wales of the Ministry of Health with a large degree of and the benefits and facilities provided are very autonomy in the health affairs of Wales.Most of similar.The Minister of Health and Local Govern- the health legislation for Scotland is drawn up sepa- ment does not administer any of the services directly. rately, following the same principles as that for England This responsibility rests with three main agencies and Wales but adapted to local conditions.In all whichexercisewide powers -viz,theNorthern health departments there are parallel hierarchies of Ireland Hospital Authority, the Northern Ireland administrative and medical staff working in liaison. General Health Services Board, and the local health The Secretary as administrative head, and the Chief authorities, which are the councils of counties and Medical Officer, have direct access to the responsible county boroughs.Thereisa medicalofficerof Minister. health for each county and county borough.The The Minister of Healthisdirectly responsible tuberculosis service is separate in Northern Ireland for: (a) the provision on a national basis of all hospital but otherwise the Hospitals Authority undertakes and specialist services; (b) mental health functions allthe functions, including the building of new concerned with medical care;(c) the conduct of hospitals, the provision of a consultant and specialist research into matters relating to the prevention, service and of facilities for medical education and diagnosis and treatment of illness or mental defect; research.It also provides bacteriological, patholo- (d) a public health laboratory service; and (e) a blood gical and blood transfusion services, not only for transfusion service.He has indirect responsibility the hospitals but for the health services in general. for the general practitioner and the local health The vital statistics for England and Wales show authority services.The Minister isadvised by a rates for 1954, 1955 and 1956 as follows: births, 15.2, Central Health Service Council, which keeps under 15.0 and 15.6; deaths, 11.3, 11.7 and 11.7; and infant review the general development of the service and mortality, 25.4, 24.9 and 23.7.For Scotland during makes special studies of any subject which in its the same years the rates were: births, 18.0, 18.0 and opinion should come to the special attention of the 18.5; deaths, 12.0 for each year, and infant mortality, Minister.The 138 Executive Councils are responsible 31.0, 30.4 and 28.3 EUROPEAN REGION 309
The National Health Service Act, which came into which is responsible under the Minister alone for org- operation in July 1948, was aimed at strengthening and anization and control.The members are appointed expanding existing services so that benefits previously by the Minister, but about half of them are nomina- available only to insured persons or to those who ted in equal numbers by the university, the teaching could afford to pay for them, or as a form of charity, staff and the Regional Hospital Boards.In Scotland should become available to everyone.About 97 per there are four such Regional Hospital Boards. cent. of the population of Great Britain are using the The detailed internal administration of individual service.The great majority of specialists are taking hospitals and small groups in England and Wales is part in it, together with almost 98 per cent. of general carried out by 388 hospital management committees, practitioners (nearly 20 000 in England and Wales, whose members are appointed by the boards after and over 2500 in Scotland).Ninety -four per cent. consultation with associations and persons concerned. of the dentists participate; of about 10 500 practising Although their powers are delegated from the regional dentists in England and Wales, approximately 9800 boards, the management committees have a substantial are in the Service, as are over 1100 Scottish dentists - autonomy. i.e., almost all the dentists in the country.Nearly In England and Wales at the end of 1955 the 2681 all chemists in Great Britain are also in the Service. hospitals in the service had 476 433 staffed beds - The total cost of the National Health Service in the about 29 000 more than in 1949.This figure included United Kingdom represents 3.5 per cent. of the total several thousand beds specially set aside for mental national resources, and in1955 -56 amounted to illness.The nursing and midwifery staff inthe £552 644 000 (US $1 547 403 200); four -fifths of the hospitals concerned comprised 143 347 whole -time gross cost falls on the Exchequer and a further portion and 32 873 part -time personnel, of whom 5362 were on local rates.Other sources of income include a whole -time midwives, 1286 were part -time midwives transfer from the National Insurance Fund and some and 3710 were pupil midwives.About 250 hospitals payment by persons using the service.To help to and homes remain outside the Service -most of them limit expenditure without reducing the services it was run by religious orders -and there are a number of found necessary to introduce charges for certain items, nursing homes, which must be registered as such.In for example, prescriptions and part of the cost of Scotland at the end of 1955 there were 400 National dentures and spectacles.The availability of the ser- Health Service hospitals, with 63 000 staffed beds and vice is not dependent on contributions to national a full -time nursing and midwifery staff of 21 300. insurance. A recent analysis of the National Health The hospital and specialist services provide all forms Service by a committee set up in 1953 showed that the of hospital care and treatment for both in- patients real cost after allowing for rising prices increased little and out -patients in every kind of hospital, in maternity during the years 1948 -54, while many of the services homes, sanatoria, infectious disease units, institutions provided were substantially expanded and improved. for the chronic sick, convalescent homes and rehabilita- Expenditure on the National Health Service in tion centres.They also provide specialist advice and Scotland amounted to £57 646 000 (US $161 408 800) treatment either in hospitals or in clinics or, if neces- in1954/55, and £61 411 000 (US $171 950 800) in sary, in the homes of the people.The domiciliary 1955/56.The Service in Scotland is very closely akin consultant service has grown rapidly since its introduc- to that of England, but central responsibility rests tion and is now a valuable link between hospital and with the Secretary of State. general practitioner.Blood transfusion and patholo- In England and Wales the 14 Regional Hospital gical laboratory services are at the disposal of every Boards, which are in general charge of the hospital and hospital.All specialist services, such as those for specialist services, operate in areas that were designed tuberculosis, mental care, etc., are available to every to secure as far as possible a close association with member of the public without any insurance qualifica- universities having a school of medicine.Each Board tions.The majority of patients are accommodated has a membership of between 22 and 32 persons ap- in general wards but some hospitals have beds in pointed by the Minister after consultation with univer- single rooms or small wards, which, if not required sities, health authorities, representatives of the medical on medical grounds, are made available to patients profession, voluntary associations, employers, trades desiring extra amenities.In such cases a charge is unions,etc.All appointments are honorary. A made representing the additional cost over the cost of number of hospitals in England and Wales have been maintenance in a general ward.There are also a designated by the Minister as teaching hospitals. number of pay beds for which patients are charged There are 36 of these, 26 being in London.Each the full hospital maintenance rate as well as the teaching hospital has its own board of governors, specialist's fee. 310 FIRST REPORT ON THE WORLD HEALTH SITUATION
Many hospitals have a department staffed by medical doctor.The group practice may or may not be social workers.Their main function is to form a link organized as a partnership.One of the most usual between the medical staff and the patients by social methods of entering general practice is to become an inquiries with the object of relieving the personal assistant to a partnership or in a group practice. anxieties of the sick, any family difficulties and other The provision of the dental service is on similar problems which arise during illness, and to ensure that lines.There is complete freedom of choice by pa- after -care and help in readjustment to normal life are tients, and the dentist has the same rights.He may provided when necessary. take both private and National Health Service patients The general practitioner service is available to every- if he wishes.Patients are not required to register one.Patients may choose the doctor they wish pro- with dentists and the ordinary practice of visiting by vided he is enrolled in the Service and consents to appointment isretained.Dentists providing treat- attend them.They may also change their doctor at ment in their own surgeries are paid on a prescribed will.The doctor has a similar freedom to accept or scale of fees.All routine dental treatment may be refuse patients, and may accept private patients.He given without reference to any outside authority, but cannot be forced to attend any person against his cases of special difficulty or long -term treatment require will, although he has a general obligation to provide the authority of the Dental Estimates Board. Ophthal- emergency treatment.The general practitioner is free mic and pharmaceutical services are organized on to treat his patients exactly as he wishes.There are no similar lines. regulations as to what drugs or treatment he may The services provided by the146 major local prescribe, although the Chief Medical Officer for the authorities in England and Wales are undertaken by Ministry offers guidance, and provision is made to the medical officer of health and his staff, working investigate improper or excessive prescribing.If any through statutory health committees.There are very special difficulty arises in diagnosis or treatment the large numbers of local authority health clinics, which doctor may call in a consultant and secure hospital are responsible for general preventive care as well as care without reference to any outside authority.The for maternal and child health services, school health, maximum permitted number of patients' names on the dental health, health education of the public, etc. principal's list is 3500 and the present average is about More than 75 per cent. of babies born in England and 2200.No doctor can be obliged to remove from his Wales are brought to infant welfare centres for regular existing practice, but he may be prevented from starting supervision by doctors and health visitors.This ser- in a new area if it is already fully served; in that vice is available until the child is five years of age. case he will be encouraged to choose a district where If treatment is required the child is referred to the doctors are most needed. A practitioner in public family doctor.Local health authorities are required service is remunerated by capitation payment for each to provide free dental care for mothers and young patient registered with him, with an addition for any children, who have special priority.Where possible, patient within the range of 501 to 1500 of this list. separate sessions are arranged for pre -school children In addition doctors may receive special mileage pay- between two and five years of age.Mothercraft ment for visiting in rural areas and financial induce- teaching is a feature of the work at ante -natal clinics ments for practising in specially difficult or unpopular and is often associated with relaxation classes for districts. A special initial allowance may also be paid expectant mothers.Teaching is continued for mothers to doctors taking up practice in areas where there is who attend the clinics with young children, and health great need.At present the general practitioner service education of this kind takes the form of individual is almost always organized from the doctor's own sur- consultations, group discussions, demonstrations and gery, to which patients go for advice and treatment special classes -for example, in infant cookery and except when the doctor visits them at home. A few making clothes for babies and young children. doctors work from health centres.It has recently been The expectant mother may arrange to have her baby urged that many of the advantages of health centres in hospital or at home.The doctor carries out ante- could be secured more easily by group practice.This natal and post -natal examinations, attends the confine- means that a number of doctors, normally between ment if he thinks it necessary and gives any other three and six principals, work from a common centre medical care required. Routine supervision and advice controlled by themselves and employ jointly any is provided by the midwife, who visits the house auxiliary help that they require, such as, for example, regularly before the confinement.As a rule the mid- nurses and secretarial staff.They co- operate in pro- wife delivers the baby, unless the doctor considers it viding a round -the -clock service for patients, but each necessary to be present, and she continues in attend- patient remains the responsibility of his own chosen ance for the first 14 days after birth.Midwives work EUROPEAN REGION 311 in close touch with child welfare centres, and when they for schoolchildren between their thirteenth and four- cease to attend the mother, or the mother returns home teenth birthdays.In a similar way, under the National after a hospital confinement, the health visitor from Assistance Act of 1948, the major local authorities the health department begins her regular visits. have power to provide welfare services for the blind, Special equipment is provided on loan to mothers deaf or dumb or those permanently and substantially whose premature babies can be nursed in their own handicapped by illness, injury or deformity.They are homes, and arrangements have been made for them also empowered to use the help of voluntary organiza- to be attended by midwives and health visitors with tions as their agents and, in the case of the blind, a special training. duty has now been imposed by the direction of the Before 1948 health visitors were primarily concerned Minister. with the general care of mothers and of children up The National Health Service Act brought mental to the age of five years.The trend, which isstill and physical health together in one comprehensive encouraged, was to use the health visitor also as service and the Minister is responsible for the whole the school nurse in her area.Under the National organization of mental health.Local health author- Health Service her role has been widened further to ities deal with community care of mental defectives include advice on the care of any person suffering from and the initial care of patients suffering from mental illness and on measures for preventing the spread of illness.They also provide after -care where neces- infection.Many health visitors take part in care and sary.The officers employed by local health authorities after -care services, especially for tuberculosis patients. are mainly local health workers who are under the A Home Nursing Service is provided under the family direction of the medical officer of health.Some doctor for those who require nursing in their own authorities have appointed an assistant medical officer homes.The nurses are employed either directly by with special duties in mental health. the local health authority or by a voluntary organiza- At the end of 1956 there were, in England and tion as its agent.About half of the nurses' time is Wales, 149 480 patients under treatment for mental devoted to nursing the aged or the chronic sick. disorders and 141 996 mental defectives were under Local health authorities have power to provide care; 78.2 per cent. of all patients admitted direct to domestic help for households where it is needed on mental hospitals were admitted voluntarily.In Scot- account of illness,childbirth, or the presence of land, the boarding -out system has always been a pro- children, old people or mental defectives.This is not minent feature of the mental health services.By the a free service but authorities make charges according end of 1955 there were 26 886 hospital beds for the to the families' means.All authorities now provide mentally ill and mentally defective compared with this service, mainly by the employment of part -time 36 180 for all other types of illness.About 72 per workers.It is especially valuable for the aged and cent,of admissions to mental hospitals are now the chronic sick. voluntary.In Northern Ireland the mental health Local authorities have power, with the approval of services are administered by the Northern Ireland the Minister, to provide, equip and maintain a new Hospitals Authorityaspart of a comprehensive type of combined health centre for the following scheme.There are six mental hospitals and three services : (a) general practice, dental and pharmaceuti- institutions for the mentally subnormal.The Hos- cal services; (b) specialist services by arrangement with pitals Authority isalso responsible for community the Regional Hospital Board; (c) the local authority mental health work. clinic services, and health education.Lack of re- A large number of voluntary associations provide sources has prevented the building of these combined welfare services for sick and handicapped persons. centres on a large scale. A few have been established Their most valuable role is probably to give personal by local health authorities and one or two experimental service to the welfare of the sick and infirm.These centres have been set up by voluntary bodies.As part agencies usually depend partly on the work of unpaid of their preventive work, local health authorities may volunteers. A great deal of voluntary help is given give help and advice to families which are in difficulties to hospitals.More than half of all the hospitals in or in danger of being broken up. England and Wales have their own " League of Mass miniature radiography was introduced in 1943 Friends " or a similar body.The main functions of and there are now about 70 units operating under the these associations are the operation of canteens for Regional Hospital Boards, and examining over three out -patientsandlibraryservicesforin- patients. million persons a year.Under a scheme launched They also take a great part in transport work, visit- in 1949 all health authorities provide BCG vaccination. ing in the wards, receiving new patients, making linen, This was expanded in 1953 to make special provision clothes, etc. 312 FIRST REPORT ON THE WORLD HEALTH SITUATION
The School Health Service, although closely co- Most of these doctors are in general practice and under- ordinated with the National Health Service, continues take part -time factory work.In addition to the its separate existence under the Ministry of Education. above, industrial medical officers have been appointed The executive work is generally carried out for the by many employers.They cover a wide range of local education authorities by the medical officer of medical and preventive work, including rehabilitation health and hisstaff.All the medical and dental and health education.There is a standing Advisory services are provided free of charge.Child guidance Committee to advise the Minister, and a number of centres for the treatment of maladjusted children are special bodies -such as the Department of Scientific made available by most of the education authorities and Industrial Research -undertake research and under the school health services and also by many large other activities. hospitals and a few voluntary organizations.Child Medical research in universities, hospitals and other guidance centres and clinics are normally staffed by institutions in the United Kingdom has been esta- teams consisting of a psychiatrist, an educational blished for many years.The principal organization psychologist and psychiatricsocial workers.The is the Medical Research Council, which is under the School Health Service in Scotland operates under the statutory authority of a committee of the Privy Education Act and the executive work is carried out Council.The Public Health Laboratory Service is by the local education authorities.The central ser- administered by the Medical Research Council for vice, however, is under the Department of Health. the Ministry of Health.Private voluntary organiza- The industrial health services are essentially pre- tions play a considerable part in medical research ventive and include first -aid treatment for accident or work in close co- operation with official bodies. sickness.The State appoints independent inspectors Professional training in medicine is controlled by (including medical inspectors) to advise on and enforce the General Medical Council, which is a statutory the enactments connected with the health of workers. body.There are 16 universities which grant degrees The employers have a general responsibility not to in medicine and surgery.In addition, the Royal endanger thelife and health of their employees. College of Physicians and the Royal College of Sur- Many of them have made arrangements, including geons (in England and in Scotland) and the Apothe- the provision of medical and nursing services, to help caries Society of London grant diplomas which are them comply with the statutory requirements. A recognized by the General Medical Council.There large number of private industrial firms maintain their are about140hospitals in Great Britain with medical own health services, and since1947the National Coal teaching facilities.The British Postgraduate Medical Board has developed its own industrial medical service. Federation is a school of the University of London. Most of the industrial premises in Great Britain come It comprises a post -graduate medical school and under the Factories Acts, which are administered by institutes in the various clinical branches of medicine the Ministry of Labour and National Service.The and surgery.The dental profession is governed by a factory inspectorate which is appointed and paid by General Dental Council, which is a statutory body. the central Government was first created in1833. Fourteen universities grant degrees in dental surgery The original staff of four inspectors and 14 sub - and, over and above this, diplomas are granted by inspectors has increased to about360and the number various colleges and faculties. of premises subject to inspection has grown from just The minimum period of hospital training required over 4000 to a quarter of a million.General require- to qualify the candidate for registration as a general ments for safety, health and welfare are supplemented nurse is three years.The theoretical work for examin- by regulations dealing with special risks in particular ations is done either at the same time as the practical industries, processes and machines.There are at nursing or, in some hospitals, at intermittent periods. present 14 medical inspectors in the factory depart- Qualified nurses are entitled to use the letters S.R.N. ment of the Ministry of Labour.Their duties include (State Registered Nurse) aftertheir names.The special investigations in industrial hygiene, the study minimum period of training for certification as a of industrial conditions in so far as these affect the midwife is one year for registered nurses and two years health of the workers, and scientific inquiries into for others. cases of industrial disease and processes directly dan- Water supply, sewerage and the prevention of river gerous to health.Factory doctors appointed under pollution in England and Wales are responsibilities the Chief Inspector of Factories carry out statutory of the Minister of Housing and Local Government. medical examinations.They also investigate cases Management of rivers is in the hands of special boards of notifiable industrial disease and certain accidents. set up under the River Boards Act,1948. Local The whole of Great Britain is covered by the service. authorities are required to supply wholesome water EUROPEAN REGION 313 to every part of their district where there are houses planning in their areas.All these functions are under or schools, to maintain wells, springs and water mains the supervision and control of the Ministry of Housing and to ensure that supplies are free from pollution. and Local Government. Recent Acts of Parliament empower the Minister to The public health functions of local authorities make grants towards schemes in rural areas.It is also include street cleansing and refuse disposal, the estimated that a piped water supply now reaches 97 per provision of baths and wash -houses, rodent control cent. of all urban households and 90 per cent. of rural and the abatement of smoke and other nuisances, dwellings. such as those arising from the processes of offensive Localauthoritieshave wideresponsibilitiesin trades. housing, the executive functions being undertaken by The Ministry of Health and the Ministry of Agri- the smaller local authorities.They are responsible culture, Fisheries and Food are the central depart- for the routine maintenance and sanitary conditions ments responsible for the purity and hygiene of food of houses and also for the clearance and re- develop- and for food protection.The larger local authorities ment of unhealthy and congestedareas.Local enforce the regulations made under the Food and authorities have important duties to relieve over- Drug Act, 1955.All premises where food for human crowding and to provide new housing accommodation consumption is prepared, sold or stored are required to meet local needs.The county councils have a to conform tocertain hygienic standards.Local general supervising authority over rural dwellings and authorities are empowered to take samples for analysis areespecially concerned with town and country and to deal with any deficiencies under the regulations.
YUGOSLAVIA
Yugoslavia is a State in the Balkans, with a long coastline Health on the Adriatic fringed by many islands, and land boundaries with Italy, Austria, Hungary, Romania, Bulgaria, Greece and The municipality (commune) is the basic social and Albania.The area is 255 804 square kilometres. economic unit of the community and is organized on The population at the 1953 census was 16 936 573, with a the principle of self -government by the local people's density of 66.3 per square kilometre.About 61 per cent. of the population live in rural areas.In 1956 Belgrade, the capital, committees.It is an economic and territorial unit, had a population of about 485000.In 1953 it was estimated that and a great number of municipalities are in fact strong 25 per cent. of the inhabitants over 10 years of age were illiterate. enough to solve their own economic, communal and According to the 1953 census, the main occupations are health problems.But in case of need it is the district agriculture (engaging over 5 million), mining (130 000), industry (530 000); commerce (240 000), and handicrafts (430 000). -which is the social and political association of the Yugoslavia is a Federal People's Republic, made up of six municipalities and forms a more or less independent Republics:Serbia,Croatia,Slovenia,Bosnia -Herzegovina, territorial and economic area -that supervises the Macedonia, and Montenegro. organization and development of social life in any In agriculture, the main crops are wheat and maize.There given region. are fairly large forest areas which could be considerably de- veloped. The Government has been encouraging industrial Within the framework of local district and municipal development and a small amount of equipment is now being committees, there are public health councils, made up exported.Minerals are a great source of wealth, especially as a rule of representatives of social organizations in the central regions.Industries are nationalized, and private (such as the Red Cross, the Association of Friends of ownership of agricultural land is limited to 10 hectares. Eight years of primary education are compulsory, and all Children, and the social insurance system) and public educationisfree.There are seven universities- Belgrade, health workers.These councils generally have nine to Zagreb, Ljubljana, Sarajevo, Skoplje, Novi Sad, and Rijeka. 15 members in the districts and five to nine members In 1957 there were about 11 800 square kilometres of normal in the municipalities. and narrow gauge railways.On the Adriatic the principal In the people's republics there are also public health ports are Rijeka, Split, Sibenik, Ploce, Dubrovnik and Kotor. The Danube is an important waterway, and in 1957 Yugoslavia councils, as in the districts and communes, made up had nearly 1200 river craft.In the same year there were of between 15 and 25 representatives of social organiza- 48 557 kilometres of macadamized and 4181 kilometres of tions, and experts in various subjects (such as university concrete or asphalt roads.There are many international air professors and medical officers of health).These services operated by Yugoslav and foreign civil airlines. In 1957, 2 821 000 people were covered for old -age, invalidity, councils have at the same time social and administra- and survivors' pensions' and the same number for benefits in tive functions, and have secretariats as their executive case of unemployment and the accidents of employment. organs. 314 FIRST REPORT ON THE WORLD HEALTH SITUATION
The Federal Assembly and the national assemblies population, such as children under school age, and of the Republics have committees for public health pupils and students of all schools, also receive care and social welfare, which are especially concerned in the dispensaries free of charge, irrespective of with programmes of health improvement and may call whether or not they are insured.Furthermore, even on the advice of experts.These committees work out if they are not insured, they pay only 50 per cent. of the the public health laws of the Republic and, in co- chargesforin- patientmedicalcareinhospital. operation with the executive council of the Republic, Members of collective agricultural co- operatives also submit them to the national Assembly. pay only 50 per cent. of the charges.Medical care Finally, there is in the Federal Executive Council a is provided free of charge to such an extent that it was Committee for Public Health and Social Policy, as recently estimated that about 80 -85 per cent. of all well as a Public Health Division headed by an Under - health services were free, the remainder being paid Secretary of State. for by individuals. In the administration of the health services as a The following table shows how the cost of health whole there is a substantial amount of decentraliza- and medical care is being borne to an increasing tion; in most cases the local bodies are responsible for extent by the national budget and health insurance: running the services, and they deal with matters which come within their jurisdiction.Experience has covered % covered % covered shown that the best way of arousing the interest of by the by social by citizens budget insurance the people in public health is to set up local councils 1954 24 59 17 responsible for organizing both curative and preventive 1955 20 64 16 services and for making studies of public health con- ditions.These councils co- ordinate the work of all health establishments and in this way are responsible The national health services budget in 1953 repre- for the health programme within their own area.In sented 2.96 per cent., and in 1955 3.27 per cent., order to secure uniformity in the health programmes of the national income.The ratio of expenditure on of the Republics, institutes of public health and curative services to expenditure on preventive services hygiene have been established in the Republics, and in 1954 and 1955 was 11.5: 1.0. the Federal Government has a Federal Institute of Health statistics are published annually in a statis- Public Health. tical yearbook.In 1956, the birth rate was 25.9, The fundamental principles on which the health the death rate was 11.2, and the infant mortality rate service was constituted are :(a) the protection and was 98.3, compared with a death rate of 14.9 in 1939, improvement of public and personal health; (b) con- and an infant mortality rate of 143 during the years trol of disease by general and specific measures; 1934 -37. (c) case -finding,early diagnosis and timelytreat- There has been a considerable extension of the ment; and (d) campaigns against ill- health and for the hospitalserviceduring the past tenyears.The rehabilitation of the handicapped.For this purpose, number of beds has doubled, and the total number of medical care and preventive services are frequently physicians has risen from 4754 in 1939 to 10 346 united to form an integrated service.The hospitals in 1956.The organization of domiciliary medical have also been included in the general health service care is not yet adequately developed, but there has and are gradually becoming less isolated; they have been a very large increase in out -patient services at begun to set up dispensary services and polyclinics dispensaries and health centres, of which there are and are thus helping to bring about the integration now more than 3000; the number of out -patient visits of out -patient, dispensary and hospital services. rose from 23 million in 1953 to 28 million in 1955. Health insurance covers about 43 per cent. of the Some 1 147 000 patients received treatment in general population; some 7 413 000 people were covered for and special hospitals in 1955, and a further 35 000 were sickness and maternity benefits in 1957.Free medical attended in other institutions such as sanatoria. advice and care are given for communicable diseases, Since the war, a series of programmes have been all forms of tuberculosis, mental disease, physical planned and carried out for the control of various handicaps, and long -term disabilities provided that epidemic and endemic diseases, and these programmes these can be cured.All mothers requiring maternity are now beginning to bear fruit.All the pre -war care, people who are unable to support themselves, institutions have been re- established and many new the aged and infirm, and all children up to three years hygiene institutes and epidemiological stations have of age are also entitled to free medical advice and care been built.With the opening of new laboratories the in all health establishments.Certain sections of the scope of these institutes has been enlarged, and various EUROPEAN REGION 315 specific studies have been undertaken on such con- about 300 chronic cases remain and no new infections ditions as brucellosis and virus diseases, especially have been noted.In Serbia more than halfthe in Belgrade, Zagreb, Sarajevo and Ljubljana.In 1955 cases have been cured, and in Croatia and Bosnia the the epidemiological stations and hygiene institutes situation is improving rapidly. employed 599 physicians, 145 public health engineers Approximate estimates show that Yugoslavia had and chemists, 51 pharmacists, 587 technical health about 1 400 000 cases of endemic goitre.In 1953 workers, and 560 hygienists and other medical tech- it was decreed that salt for human and animal con- nicians.The local district and municipal committees sumption must be iodized; most encouraging results employed separately a very substantial number of have already been obtained from the compulsory con- health workers. sumption of iodized salt -the number of cases of Malaria control was begun in 1947, and has achieved goitre in young children has decreased by 50 per cent. considerable success.Since that time there has been in five years, and in as many as 72 -87 per cent. of a very rapid decline in the number of cases, from cases, manifest goitre has completely disappeared. several hundred thousand to 600 in 1953 and some There has been a steady increase in child health 800 in 1957. services, as shown by the fact that between 1953 and Tuberculosis is still a major problem, and a survey 1955 alone the number of children's dispensaries rose made in 1955 revealed that about 1.7 per cent. of the from 132 to 159, and the number of school health people were actively infected.The health service has centres and polyclinics increased from 120 to 155. undertaken a series of measures for the control of the The same is true of maternal health services.Since disease, including an increase in institutional accom- the war the number of beds for maternity cases in modation and in the number of dispensaries and hospitals and maternity homes has increased and specialists.Before the war there were only 2800 hos- many new clinics have been opened.The growth of pital beds and 49 dispensaries for tuberculosis patients, these services is illustrated by comparative statistics whereas by the end of 1955 the number of beds had for 1950 and 1956: in 1950, there were 237 dispensaries risen to 17 000 and the number of dispensaries to 226, for women and 682 000 visits were recorded, whereas apart from eight static and 10 mobile x -ray units. in 1956 the number of dispensaries had risen to 401, BCG vaccination was made compulsory in 1948, and and1 040 000visitswererecorded.Many pro- since then over nine million children and young people fessional courses on maternal and child health are have been tuberculin- tested, and nearly four million of being given to general practitioners, and the training them have been vaccinated.Before the war, the of midwives is being improved. tuberculosis control service was staffed by 50 physicians In recent years there have been great improvements and 76 nurses, as well as a number of x -ray technicians in the dental service.In 1956 there were 1697 qualified and laboratory assistants in the dispensaries; in the dentists and 1414 dental technicians, and 946 dental ten years since the war the number of staff had treatment centres for out -patients were in operation. increased by 474 per cent. With the object of preventing accidents and pro- After the war it was decided to organize a campaign tectinghealth during working hours,thehealth to eradicate endemic syphilis, which was prevalent in authorities have devoted special attention to the certain areas of Serbia and Bosnia.Field teams were establishment of health services in factories, mines and sent to make investigations on the spot and to treat all concerns employing large numbers of workers. detected cases.They toured the villages, making The rehabilitation of the sick and injured has house -to -house inspections and carrying out serological become an essential part of the work of public health tests; altogether, 1 841 898 people were examined and centres.After the war, these institutions were over- given blood tests, and on the basis of these examina- burdened with the care of disabled ex- service men, and tions 98 066 cases were found and treated.Endemic it was not until 1949 that a new and wider rehabilitation syphilis in Yugoslavia has now been brought under service was first organized.The first centre (which control, and further care can be left to the local hassince been converted into an institute)was health services. established in 1952, and from then onwards the idea The number of cases of trachoma has not been spread widely, so that all the Republics have now set accurately estimated, but it almost certainly amounts to up their own centres.Steps have also been taken to more than 30 000.Campaigns for the control of this train staff for this purpose, particularly at the school disease were conducted before the war, but after the of physiotherapy in Zagreb (Croatia) and the Institute war they were considerably strengthened, and have for Rehabilitation in Belgrade (Serbia), and similar been especiallyeffectiveinSlovenia, where only courses are also being organized in other Republics.
EASTERN MEDITERRANEAN REGION FIG. 10. EASTERN MEDITERRANEAN REGION ADEN (COLONY AND PROTECTORATE)
The Colony of Aden is a volcanic peninsula on the south coast the mission hospital provide a further 156 beds; of Arabia, about 160 kilometres east of the Straits of Bab-el - 2481 patients were admitted to these two hospitals Mandeb.The Protectorate lies to the east, west and north of the Colony, which includes the islands of Perim and Kamaran. in 1956. The climate is hot and dry and a large part of the Protectorate is The health personnel in Aden Colony in 1956 con- desert. sisted of the Director of Medical Services, the medical The area of the Colony is 192 square kilometres and the popu- superintendent of the civil hospital, the medical super- lation at the 1946 census was 80 516, including 58 455 Arabs and 9456 Indians and Pakistani.At the 1955 census the population intendent of the Maternity Hospital, a surgeon spe- had increased to 138 441.The Protectorate has an area of cialist, 26 medical officers, 15 assistant medical officers 280 000 square kilometres, and at the end of 1954 the population (13 male and two female), two matrons, 37 nursing sis- was estimated at 810 000.Many of the people of the Protector- ters, one dental officer (part- time), and 251 medical ate are nomads. auxiliaries. The economy of the Colony depends largely on the trans- shipment and warehousing trade and on the port's bunkering There are no local facilities for training students facilities.There are fisheries, some minor industries -including in medicine or nursing, and government scholarships salt production -and in 1952 the Anglo- Iranian Oil Company are provided for this.In 1954 five men had been began to construct a refinery and a new oil port, with a production trained as State Registered male nurses, and six scholar- capacity of 5 000 000 tons a year. The Protectorate's economy is based on agriculture, animal ship- holders were studying medicine in the United husbandry and fisheries.Cotton cultivation has increased in Kingdom. recent years, and other important crops are millet, dates and Pneumonia, dysentery,tuberculosis and malaria sesame. were the most important diseases in the Colony in the In Aden Colony, education in government primary schools period under review.Routine mosquito control is is free.Small fees are charged at government intermediate schools, at Aden College and at the Technical College.Teacher carried out and all the reported cases (1535 in 1954, training for men is provided at Aden College and for women 769 in 1955 and 617 in 1956) came from outside the at the government intermediate school forgirls. Selected Colony.Tuberculosis is not notifiable, but 815 new students are awarded scholarships for teacher training courses cases of pulmonary tuberculosis were seen at the in the United Kingdom. tuberculosis clinic in 1956 and 85 deaths were recorded from this disease in the same year. Health Aden Protectorate.The Aden Protectorate Health Service is headed by a health adviser, based at Mukalla, Aden Colony.The Medical Department of the with assistant health advisers in the Western and Colony is administered by the Director of Medical Eastern Protectorates.The health adviser administers Services and consists of the civil hospital, the mater- the government health service and advises the states nity hospital, the port health office, the public health of the Protectorate on health matters.The assistant department under the medical officer of health with health advisers deputize for him, are also honorary an assistant medical officer of health and a health consultants to hospitals in their areas, and control or inspector, and three dispensaries. contribute to the tuition in the training centres. The expenditure on health for the Colony for the Senior medical officers are in charge of four state financial year 1954/55 was 6.8 per cent. of ordinary (Lahej, Qu'aiti and Kathiri) or joint state (Fadhli- expenditure, and represented roughly £7.5 (US $21.00) Lower Yafai) health services, and the Qu'aiti has in per capita. addition three district medical officers in charge of the The vital statistics for the years 1954, 1955 and 1956 districts.All these state health services are based were as follows: on hospitals; that for the Qu'aiti Western District is 1954 1955 1956 planned for the near future in Duan.Health units Birth rate 22.8 29.3 32.7 Death rate 10.8 12.8 12.9 are administered from parent hospitals, and number Infant mortality rate . . . . 156.0 159.0 151.0 34 in the Western and 33 in the Eastern Protectorate. There are two mobile sanitation units, with health The government civil hospital has 360 beds, with a inspectors in charge, one based on Makhzan and one tuberculosis unit of 138 beds, and in 1956 recorded on Mukalla, associated with the training centres at 5449 admissions; the government maternity hospital, these bases. with 50 beds, admitted 2600 patients in the same year. There are three state health boards (Fadhli -Lower The Aden Petroleum Refinery Limited Hospital and Yafai, Qu'aiti and Kathiri), which discuss such matters - 319 - 320 FIRST REPORT ON THE WORLD HEALTH SITUATION as policy, legislation, estimates, buildings and licensing No figures for births and deaths are available; infant of practitioners and drug -sellers, and pass their re- mortality is known to be high in places, reaching as commendations to the state councils. much as 500 per 1000 live births. The staff engaged on health work in the Protectorate From the cases admitted to, or treated by, hospitals has increased since 1951, and in 1956 the senior staff and health units, it may be seen that malaria and other consisted of 14 doctors (10 government, four private), fevers, intestinal infections, ulcers. eye diseases and and two nurses of senior training (both private).The pulmonary tuberculosis are of importance.The group government hospitalstaff comprised 18 technical of undifferentiated fevers includes some malaria and (hospital,theatre,radiographical,laboratory and also infective hepatitis, sandfly fever, dengue, influenza pharmacy) assistants;seven head sick -attendants, and, it is suspected, a not inconsiderable amount of 26 sick -attendants (male and female) and approxi- poliomyelitis.During the period under review there mately 25 trainees.District staff, employed by either were no cases of the six quarantinable diseases. the Government or the states, consisted of 52 health By the end of 1956 malaria was being controlled to assistants, seven health inspectors, five health overseers an increasing degree, though there were occasional and four health technicians. epidemics.More and more attention is being given The total expenditure on health for the fiscal year to pulmonary tuberculosis by registration,leaflet 1953/54 was £67 212 (US $188 194),for1954/55, propaganda, domiciliary care and hospital care where £111 747 (US $312 892) and for1955/56, £87 426 necessary and possible.In 1956 the number of cases (US $244 793). being brought to treatment had increased by some There are five State hospitals in the Protectorate, 300 per cent. since 1951, and a BCG vaccination cam- each with laboratory facilities, and with a total of paign was planned. 120 beds (in 1955); 1465 in- patients and 42 476 out- The number of leprosy patients registered in 1956 patients were cared for in these hospitals during was 63 in the Western Protectorate and 115 in the 1956. Eastern; these figures are minimal, but the disease The health units are staffed by health assistants, is not a major public health problem.Domestic who work under the supervision of visiting district segregation and domiciliary treatment are applied doctors and who are trained in preventive as well as when feasible. curative skills.In 1956 the 34 health units in the Trachoma is widespread, and a drive against eye Western Protectorate handled 100 874 cases, including diseases was started in 1951; since then the number of 14 035 home visits, 161 567 treatments, and 1198 im- cases tracked down and treated has increased more munizations (smallpox, cholera and yellow fever); than tenfold. 7995 homes were sprayed.In the Eastern Protector- Sanitation is very primitive, and the lack of it is ate during the same year the 33 health units dealt with the greatest single danger to health.In the Eastern 47 247 cases, including 5088 home visits and 195 788 Protectorate the constant efforts which are being treatments; 2957 homes were sprayed. made to render privies fly -proof are proving successful.
CYPRUS
Cyprus is an island in the eastern Mediterranean basin. the 1946 census, 25.6 per cent. of the population between 16 and The summer climate is hot and dry in the plains and humid on 60 years age (most of them over 50) were illiterate. the sea coast; the climate in the hills is equable and bracing. The area is 9251 square kilometres, and the estimated total Health population was 498 000 in 1952, 513 700 in 1954, and 527 800 in 1956. The history of the public health services dates back For administrative purposes the islandisdividedinto to the time of the British occupation of the island six districts, and there are municipal authorities in the larger 80 years ago.Malaria took a heavy toll particularly towns. The territory is predominantly agricultural.Minerals account among the younger age -groups and stood as a for- for about half the value of all domestic exports.Industry is as midable obstacle to the island's prosperity.At the yet relatively little developed. beginning of this century Ronald Ross visited the Government- controlled primary education is free but not island to advise on practical methods of malaria compulsory and about 95 per cent. of the children attend school. All secondary schools charge fees. Teaching is in Greek or control.During this period locally trained sanitary Turkish, English being taught as a subject.About 300 Cypriots inspectors were appointed to assist in the prevention are engaged in higher studies in the United Kingdom. At of disease and the improvement of environmental EASTERN MEDITERRANEAN REGION 321 sanitation.Later on trained healthofficers were The technical staff of the public health service appointed and the preventive services were organized includes 81 physicians (specialists and general duty and expanded. medical officers); 56 nurses of senior training; 136 nurses The public health service which had thus been estab- locally trained; 196 nursing aides; 20 midwives of lished gradually improved with the passage of time. senior training; 40 midwives locally trained; 55 health In the late 1940's a malaria eradication scheme was inspectors;21laboratory and x -raytechnicians; started and by 1950 malaria had been almost com- 37 pharmacists; three physiotherapists and assistant pletely eradicated from the island.Hospitals and physiotherapists. other institutions were built in the main towns and in There are no medical schools, and training of public some of the larger villages; ante -natal and child health medical personnel is not undertaken in Cyprus. welfare centres were opened and environmental sanita- A certain number of fellowships are awarded by the tion was considerably improved.All these factors, Government to medical officers, enabling them to combined with the excellent climate and the absence obtain post -graduate training outside the country in of the most formidable communicable diseases, created various branches of medicine and public health. a standard of health and a socio- economic situation There are training courses for community health visi- bearing favourable comparison with conditions in tors, and there are schools for nurses, sanitarians and several European countries. auxiliary personnel.Recruitment of nurses constitutes The Government assumes responsibility for social a notable problem; the number of educated girls who security, the treatment of the sick and the prevention show a desire for the profession is too small to fill of disease, and these services are available to every the needs of the service. class of society and cover every part of the island. Registration of births and deaths is compulsory by For the lower income groups hospital treatment is law, but figures for 1955 and 1956 had to be estimated provided free or at a nominal cost.Prophylactic on the basis of the last three years' trends because a inoculations against diphtheria, typhoid and large proportion of the mukhtars responsible for the whooping -cough are given free. registration submitted their resignation. The Director of Medical Services is the central Vital statistics for the period under review were authority for the organization, planning and co- ordina- estimated as follows : tion of all curative and preventive services.He is 1954 1955 1956 assisted by two assistant directors, one responsible for Birth rate 27.0 26.4 26.4 Death rate 7.2 5.8 6.3 hospital administration and the other for the preventive Infant mortality rate . . . 52.0 31.5 31.7 services.Other members of the technical staff are a chief health inspector, a senior health visitor, an The main causes of death for the whole population inspector of pharmacies and a chief pharmacist. were arteriosclerosis and heart diseases; accidents; The district medical officerisresponsible for all vascular lesions affecting the central nervous system, curative and preventive measures inhisdistrict. and senility. Important infectious diseases are: diph- Under his supervision rural medical officers are in theria, with a mean incidence of 19 per 100 000 popu- charge of groups of villages (each group containing lation; enteric fever, with 18 per 100 000; and tuber- some 10 000 population), assisted by a pharmacist, culosis, with 37 per 100 000.The incidence of venereal a health inspector, a midwife and in some areas a disease showed a marked decrease during the years health visitor.The health responsibilities of local underreview. Trachoma,widespreaduntilthe authorities -the municipal authorities in the towns and beginning of this century, has shown a gradual but steady larger villages -are concerned mainly with sanitation. decrease, particularly in the last two decades.Returns Voluntary organizations such as the Anti -Tuberculosis for 1954 -56 showed a mean incidence of 21 per 100 000 League, the Red Cross and others give valuable population, and this disease has therefore ceased to be assistance to the health services and also to welfare a public health problem.Judging from the number work. of patients requiring surgical treatment, hydatidosis There are 339 registered private practitioners in the can be taken to be fairly widespread. island.This total, added to the number of govern- The attention of the central health authority has been ment- employed physicians, theoretically gives a ratio directed towards the further improvement of services of one doctor to every 1255 inhabitants.Most private in the rural areas. A scheme for transforming the practitioners, however, practise in the larger towns. existing rural medical stations into health centres There are some 53 private hospitals, with a total of has received official approval and is expected to be put 880 beds, as well as 21 government hospitals, and in operation soon.Long- and short -range health the ratio of hospital beds to population is 4.5: 1000. planning activities include an extensive BCG vaccina- 322 FIRST REPORT ON THE WORLD HEALTH SITUATION
tion campaign, the reorganization of the rural health are placed on probation or in special hostels, and services, the organization of a school health service, supervised by trained probation officers.Homes for plans for a new and modern mental hospital and children and young persons in need of protection have proposals for a comprehensive public health law. been established in all main towns. As far as the control of endemic diseases and other Altogether 13 028 in- patients received treatment in diseases of social importance is concerned, BCG vac- hospitals during 1956, as compared with 13 261 in 1955 cination is offered to selected groups, such as public and 12 568 in 1954.An extensive hospital building health workers,police,tuberculosis contacts and programme has been carried out during the period schoolchildren over the age of 12 years.There are under review.The out -patients who received treat- two sanatoria with 150 beds in the island and there is ment at the government out -patient dispensaries and no waiting list for tuberculosis cases.Chest clinics health centres during 1956 numbered 142 951, as function in the main towns of the island and are visited compared with 157 092 in 1955 and 164 643 in 1954. regularly by two tuberculosis specialists.Each of the The standard of nutrition of the whole population is district hospitals has a venereal disease clinic and there considered satisfactory.All essential foodstuffs are are also some 12 prophylactic centres operating either readily available and fruits and vegetables are abun- under municipal or under military control.Treatment dant, but there is a tendency towards diets of too high of venereal diseases in government institutionsis a caloric value, owing to the excessive consumption of offered free of charge.Although malaria is practically carbohydrates and oily foods. eradicated, a team of sanitary inspectors and labourers Housing conditions in the towns and large villages is permanently engaged in checking potential breeding - are satisfactory, but there is considerable room for places and spraying activities in view of the possibility improvement in the remoter hill villages and those of of the introduction into the island of Anopheles from the plains, where badly constructed houses and over- countries where malariaisstillprevalent.Insect crowding are common control measures are also applied to all incoming ships The sanitation, ventilation, cleanliness, etc. of pre- and aircraft. mises where work is carried out, and the health, safety Health education of the public forms part of the and welfare of persons employed are controlled and duties of the Medical Department.Medical officers, maintained in accordance with the Factories Law. health inspectors and health visitors are responsible Health hazards in industry have been reduced but for conducting a health education campaign through there are still numerous accidental injuries occurring talks and demonstrations todifferent population among unskilled labourers.Although the mining groups.Posters, bulletins, the press and radio are industry is the main mass labour -employing under- also used for the purpose. taking, pneumoconiosis has not yet been observed. Ante -natal clinics are attached to all government Temporary or permanent disability occurring during hospitals and most of the rural medical centres of the employment is compensated under the Workmen's island.Owing to the considerable demand for insti- Compensation Law. tutional delivery, admission to government hospitals Water supplies have been greatly improved during is limited to primiparae and those found to present recent years.In every town and in the majority of abnormalities at the ante -natal clinics.There are the villages there is now an adequate piped and safe 60 government -employed midwives and 425 private water supply.Sixty -two per cent. of the villages are midwives -a ratio of one midwife to approximately provided with a piped water supply, 16 per cent. 1100 of the population.All towns, and some of the have a piped water supply requiring repairs or pipe larger villages, have child welfare centres and some replacement or redistribution, and only 20 per cent. of them also have day nurseries and play centres.So of the villages are without a piped supply, on account far, no organized school health service exists, but a pilot of their distance from reliable sources.The question service has recently been introduced, and it is planned of refuse and sewage disposal has attracted official to extend it to other schools in the near future. attention.There are as yet no sewage plants in the Plans for a modern mental hospital have been pre- island, but plans are being made for their installation pared.Meanwhile, the old mental hospital continues in certain places.In the towns and in some villages to function in its old- fashioned building, where more individual septic tanks and soak -away pits are used; than 500 patients are treated under overcrowded con- in the villages dry pit latrines are in more common use. ditions.Juvenile delinquency, although not a big Both methods have proved satisfactory, and as the problem, is dealt with adequately.In addition to a result of an extensive privy construction campaign reform school, a scheme is in operation whereby only a small proportion of houses in some rural areas maladjusted or delinquent children and young persons are still without a sanitary convenience. EASTERN MEDITERRANEAN REGION 323
EGYPT1
Egypt forms the north -eastern extremity of the continent of Health Africa.It is bounded on the north by the Mediterranean, on the east by the Gulf of Akaba and the Red Sea, on the The first sanitary administration in Egypt was estab- south by Sudan and on the west by Libya.The total area is lished in 1798.Its duties were the control of epide- one million square kilometres of which only a little over 35 000 mics, the supervision of medical services for the army are at present habitable.The main divisions are: Egypt proper and for civilians, and the ensuring of general clean- (the Nile Valley or Upper Egypt and the Nile Delta or Lower liness and public health. Egypt), the Western Desert, the Southern Desert, the Eastern or In 1827 the medical school was founded, and a year Arabian Desert, and the Peninsula of Sinai.The city of Cairo, later schools of pharmacy and veterinary medicine the capital, is situated between Upper and Lower Egypt on were attached to it.In 1831, a Board of Health 30° north, and has a population of about three million.Except was established to supervise maritime sanitary ques- for the northern coastal area, where the climate is Mediterra- tions and quarantine control.In 1886 the medical nean, Egypt has a continental climate. At the last census, in 1947, the population was just over and public health services were administered by two 19 million and the estimated figure for 1957 is about 24 million. main boards: the Sanitary Maritime and Quarantine This would give a density of 22 per square kilometre, but if Board in Alexandria and the Department of Public cultivable land alone is taken into consideration the density Health in Cairo under the Ministry of the Interior. would rise to 540.The urban population accounts for a little In 1920 the Department of Public Health was headed over 30 per cent. of the total.Agriculture is the main occupa- by an Under -Secretary of State and remained attached tion, employing 7 554 614 persons according to the latest census. to the Ministry of the Interior.It included four Manufacture and commerce come next, occupying 708 776 and sections: sanitation, general hospitals, eye diseases 620 288 respectively. and epidemics.From 1920 to 1936, new sections Administratively, Egypt is divided into several Governorates, were added -for childwelfare,leprosy,endemic one for each of the big cities such as Cairo, Alexandria, Suez and Port Said, eight for Upper and eight for Lower Egypt, diseases, etc. A tuberculosis control campaign was and one each for the Western, Southern and Eastern Deserts and launched. A research institute and a few rural hospi- the Peninsula of Sinai. tals and out -patient clinics were also established during The powers of provincial councils were extended in 1934, this period.In 1936 the Department of Health was especially for education, public health and agricultural matters. converted into a Ministry.More rural hospitals were The number of members varies between 10 and 18, in part setup.Sectionsforhealtheducation,venereal elected and in part nominated ex officio.There are now diseases and bilharziasis control were established in 216 municipal and rural councils, which have power to impose the Ministry.In 1942 a law for rural health improve- local rates.Principal imports include machinery and electrical ment was promulgated.Provision was made for equipment. setting up a health services unit for communities of In 1933, elementary education was made compulsory and free for all children between the ages of 6 and 12, primary education 15 000 inhabitants. was made free in 1933 also, and secondary education was made Since 1952 the Ministry of Public Health has as- free in 1950.The total number of scholars of all kinds amounted sumed a greater responsibility for providing health to about two million in 1957.There are four universities services for the entire population, in close co- operation -Cairo, Alexandria, Mn Shams and Assyout -with a total with other social services.In its present form, the student body in 1957 of 64 211. Ministry of Public Health is headed by a Minister, There is heavy international traffic through the Suez Canal, assisted by an Under -Secretary of State and three and Cairo is an important centre of international air traffic. assistant Under -Secretaries.The Under -Secretary of A good deal of stress has been laid on improving both railways Statesupervisesdirectly the Technical Inspection and roads under a five -year programme started in 1954.The Department, the School Health Department and the 70 000 or so kilometres of railways are owned and worked by the State. Central Administration Department.In addition, There are social security schemes covering old age, invalidity he advises on problems of special importance referred and survivors' pensions. to him by the assistant Under -Secretaries.Each assistant Under -Secretary is in charge of a group of departments, arranged as follows : 1 On 2 February 1958 the Republics of Egypt and Syria were (1) General Hospitals, Social Health, Mental Health, united into the United Arab Republic. Eye Diseases, Stores; 324 FIRST REPORT ON THE WORLD HEALTH SITUATION
(2) Endemic Diseases, Quarantine, Preventive Me- HigherInstituteof Nursing, four undergraduate dicine, Rural Health and Sanitation, Technical Re- schools of nursing, 12 schools for assistant nurses, search; and 22 schools for assistant midwives and health (3) Chest Diseases, Medical Commission, Labora- visitors. tories, Pharmacies. Under the Epidemic Diseases Section of the Ministry of Public Health there are 207 health units engaged in As regards local organization, each Governorate is preventive measures for the control of epidemic under a chief medical officer, who represents the central diseases.Primary vaccination of infants up to three health administration and supervises all health and months of age against smallpox is compulsory, and medical services in the Governorate.He is assisted the whole population is vaccinated every four years. by a number of senior medical officers, one for medical Since 1944 there has been no epidemic of smallpox. services, one for preventive services, and one for rural No cholera cases have been reported since1948. health.Each Governorate is divided into a number of All pilgrims leaving for the Mecca pilgrimage are local health areas, in each of which public health work inoculated against smallpox, cholera and typhoid, is the responsibility of a local medical officer of health. and control measures are also applied to those return- Other Ministries also co- operate to a certain extent ing from the pilgrimage as well as their families. in the health field.For example, the Fellah Division In 1956 there were in operation 33 fever hospitals of the Ministry of Social Affairs, which deals with the throughout thecountry,14 permanent isolation social problems of villages, has established approxi- centres and 22 tent cordons -providing a total of mately 120 social centres, whose activities include agri- 5000 beds. culture,sanitation, homecraft and industries, and In 1956 there were 60 dispensaries for the control health.The Ministry of Agriculture (which is respon- of tuberculosis, and 12 more were due to open in 1958. sible, inter alia, for the control of animal diseases) has Beds for tuberculosispatientsaredistributedas also established a number of agricultural centres follows : 6800 for pulmonary cases, 675 for cases of throughout the country for teaching and demonstra- bone and joint tuberculosis, and 140 beds for children tion purposes which co- operate with the Ministry of in a preventorium.There is also one colony in which Social Affairs in thefield of social welfare.In 80 familiesare under observation.The General municipal areas the Ministry of Municipalities has Anti -Tuberculosis Association has introduced a scheme taken over some of the responsibilities of the Ministry of domiciliary treatment in15dispensariesand of Public Health in environmental sanitation questions. also renders social aid to tuberculosis patients and The Ministry of Education is in charge of university their families.There are 12 mass x -ray units attached hospitals (11 hospitals with 5920 beds), which are to the more crowded dispensaries, for the examination considered to be teaching hospitals. of patients from adjacent areas.There are also five The Ministry of Public Health, assisted by WHO, mobile units for the examination of schoolchildren, established a Demonstration Centre at Qalyub to factory workers, recruits and inhabitants of rural demonstrate methods of effective and efficient co- areas.In 1957 there were 12 BCG centres and 22 ordination and integration of all types of services, and mobile BCG teams, which in that year carried out to train the staff needed in public health centres. tuberculin tests on 555 511 persons and vaccinations There has been a steady increase in the national on 167 878 persons. health budget: in 1956 the expenditure of the Ministry Leprosy control in Egypt commenced in1929. of Health was about LE 0.4 (US $1.15) per capita, Until 1956, 10 out -patient leprosy clinics with isolation constituting approximately 4 per cent. of the total wards and branches in the adjacent centres for examin- State revenue during the year 1956/57. ation and treatment, and two leprosy settlements, had In 1953, the last year for which vital statistics are been established.In 1954, 1955 and 1956, 1027, 1286 available, the crude death rate was stated to be and 1348 leprosy patients respectively were isolated, 19.6, the crude birth rate 42.5, and the infant mortality most of them in the two settlements.The number rate 146. of cases discovered annually by the above services In 1957 there were 98 general hospitals in the was 847 in 1954, 772 in 1955 and 807 in 1956.Sulfon- country, 24 in large cities and capitals of the Governor- amides were used for treatment.Owing to social ates and 74 in districts and important towns, with a prejudices there have been problems in the rehabilita- total of 6930 beds. tion of the patients released from the two colonies There are three Faculties of Medicine, two Faculties after cure. of Pharmacy, two Faculties of Dentistry, a High A malaria eradication project is now under consider- Institute of Public Health, a Sanitary Institute, a ation by the Government.The Malaria Eradication EASTERN MEDITERRANEAN REGION 325
Section of the Ministry of Public Health comprises Each year, during the three years 1954 -56, there were an administrative service, a parasitological laboratory, about 1 600 000 trachoma patients. statistical and engineering branches as well as a In 1942 the Rural Health Reform Law was pro- mosquito control service for Cairo.Between 1954 mulgated in which provision was made for setting and 1956, 42 malaria centres and 67 sub -centres were up a rural health centre for every 15 000 rural popula- in operation throughout the Egyptian Region.The tion. A Rural Health Department was therefore staff engaged in malaria control work totalled 2287 created in the Ministry of Public Health in which four at the end of 1956.Some 348 515 houses and other sections were established to deal with rural health structures were sprayed with residual insecticides in centres, sanitary engineering, child welfare and admi- 1954, and 415 652 in1955.The population thus nistration.This department also organizes training directly protected was 2 630 886 in 1954 and 3 207 501 courses for medical officers, midwives, assistant mid- in 1955, the number of inhabitants living in malarious wives and sanitary overseers before such personnel regions amounting to 14 675 200 in 1954.Anti -larval take up duties in the rural health centres. measures were also taken.New malaria cases regis- Recognizing the need for better co- ordination and tered in 1954 and 1955 were 1563 and 1642 respectively. integration of all public services provided by various The Venereal Diseases Section of the Ministry of Ministries in the interest of people in rural areas, the Public Health is in charge of two hospitals, with out- Permanent Council of Social Services initiated a pro- patient clinics, in Cairo and Alexandria, 41out- ject in 1954 to erect 863 combined centres (community patient clinics in different parts of the country and centres).Up to the end of 1957, only 250 such seven mobile units.The incidence of syphilisis centres had been established.The combined centre reported to be declining. includes a medical section, an education section, a Snail control measures were taken against bilhar- social section and an agricultural extension centre, ziasis in 10 Governorates in Egypt, as well as in three all working together as one unit. oases of the Western Desert.In view of the shortage The Child Welfare Section of the Ministry of Public of molluscicides, generalized snail control measures Health is in charge of 16 child welfare centres in Cairo, were taken only in certain restricted areas, and empha- 67 centres in other parts of the country, one children's sis was laid on the treatment of sites found to harbour home and three sanatoria.Among the staff of the snails infested with schistosoma cercariae.On an child welfare centres are 98 medical officers, 48 female average, over one million examinations were made doctors, 20 pharmacists, seven assistant pharmacists, yearly of streams totalling about 300 000 kilometres fivemidwife -supvervisors,65midwives and 448 in length, about 25 per cent. of which were found to assistant midwives.The section has also under its harbour vectorsnails.During the period under supervision 22 schools for assistant midwives and six review the number of field laboratories for the examina- schools for dayas (local traditional midwives).In tion of snails increased from 52 to 70.Copper 1956 a total of 169 120 confinements were attended by sulfate was applied in14 000 -24 000 sitesyearly, the services under this section. totalling stretches of 13 000 -14 000 kilometres, and The Health Education and Social Services Section 1200 -1900 tons of copper sulfate were used.Research of the Ministry of Public Health is in charge of projects are under way in order to determine the 20 " social health services offices " throughout the efficacy of new molluscicides such as sodium penta- country carrying out health education through public chlorophenate and to study snail ecology and infec- talks and meetings held in various places such as tion patterns with a view to improving methods of schools, market places and social and religious institu- irrigation and environmental sanitation. tions. The Ophthalmic Section of the Ministry of Public A national NutritionInstitute was established Health had under its charge, in 1956, 28 separate recently to carry out studies and plan programmes ophthalmic hospitals, 66 ophthalmic units in general with the object of raising the nutritional level of the hospitals, and 17 mobile teams for the prevention as population. A recent survey shows that there has well as for the medical and surgical treatment of been some increase in the per capita intake of calories trachoma and other communicable eyediseases. and proteins during the period under review. 326 FIRST REPORT ON THE WORLD HEALTH SITUATION
ETHIOPIA
Ethiopia is in east central Africa.It is bounded on the north During the period under review there were in the by the Red Sea, on the east by the Somalilands, on the south country, under both Government and private auspices, by Kenya and on the west by Sudan.The province of Eritrea was federated with Ethiopia in 1952.The area is just over a total of 54 hospitals and 362 clinics, comprising v one million square kilometres.The country is mainly moun- 5774 beds.In all 132 doctors were employed by the tainous, several peaks rising to over 5000 metres, chiefly in national, provincial, and local authorities, as well the centre and the north.The high plateaux are well watered as by the missions.In addition there were 31 private and have a pleasant climate, but the lower country and the valley gorges are very hot.On the plateau there is a dry practitioners, 160 nurses, 12 pharmacists and 1367 season from October to June and a wet season from June to dressers. September.The Blue Nile is the principal river. Malaria is a serious problem all over the country, No census figures have been given, but the population was last with the exception of some parts of the highlands estimated (in 1954) at 17 million.The most important race above2000metres.Pilotprojectsformalaria are the Amhara, who inhabit the central highlands.North of them are the Tigré; both of these are of mixed Hamitic and control have been initiated.Typhus, mostly louse - Semitic origin, further mixed by intermarriage with Galla and - borne, is endemic, but with vaccination campaigns other races.The Gallas constitute large communities and are the incidence is decreasing.Smallpox is also endemic, a pastoral people of Hamitic origin.Somalis and Danakil are but vaccination is compulsory and iscarried out on the eastern border and there are Nilotic tribes in the south- west.The main occupations are pastoral and agricultural. in towns where there are health service facilities. Addis Ababa, the capital, has a population of about 400 000. Relapsing feverisalsoreported.Bilharziasisis Local produce includes coffee, hides, skins, wax and wheat, found sporadically on the Sudan and Somalia borders, in quantity sufficient for export.The principal imports are in Eritrea and in a few other scattered places.The salt, cotton goods, building materials, petrol and kerosene, vector snails are found all over the country but are sugar, glass, machinery and soap. There are 10 secondary schools in Ethiopia, with 2294 pupils, notusuallyinfected.Trachoma showsahigh a secondary school for 450 girls, and a teachers' training college incidence. with 80 students.There are also commercial, technical and Tuberculosis is one of the most widespread and handicraft schools.Elementary schools have places for some serious diseases. A country -wide BCG vaccination 7000 pupils.School attendance throughout the country is estimated at about 60 000 atthe government schools.In campaign has been carried out. A venereal disease Coptic Church schools there are an additional 55 000 children control programme has been in progress for some who are being taught to read and write.There is a University years.Other important infectious diseases are dysen- College in Addis Ababa, with a two -year training course, pre- tery,salmonelloses, infectious hepatitis, whooping - paring students for examinations at the intermediate level at cough, measles and leprosy.Poliomyelitisis London University, or for corresponding entrance tests at other not universities abroad.There exists also in this college a post - common.Cholera, plague and yellow fever have intermediatetraining programme leadingtoa Bachelor's not been reported. degree.The training is organized in two faculties: an Arts A mobile health team has been organized to extend Faculty (with four sections) and a Science Faculty (with three services to the remote areas and to investigate the sections -one of which trains assistant doctors and laboratory chemists).The medical subjects taught include biology, com- prevalence of diseases and the general health conditions parative anatomy, genetics,histology, embryology, general of the people. physiology and bacteriology. Maternal and child health care is included in the A railway runs from Djibouti in French Somaliland to Addis general health services.During the period under Ababa, with trains about three times weekly in each direction. review Ethiopia is linked by air with Cairo, Athens, Karachi and special maternal and child healthclinics various other cities. have been established in a few places. A health education section under a qualified health educator Health has recently been set up in the Ministry of Health. No complete medical school exists in the country, The Ministry of Health, which was set up in 1947, but pre -medical teaching is carried out at the Uni- is divided into a central administration and a provincial versity College in Addis Ababa and in Asmara. and local administration.The central administration There are five schools for nurses, and training facilities consists of a Department of Health and a General for sanitarians and other auxiliary personnel. An Advisory Board of Health.In the provinces each outstanding achievement is the establishment of the Governor- general is responsible for the public health Haile Selassie Public Health College and Training in his province and is assisted by a provincial health Centre at Gondar.The object of the Centre, which officer and a Provincial Advisory Health Council. includes a hospital with 150 beds, a laboratory and EASTERN MEDITERRANEAN REGION 327 urban and rural training centres, is to train three centres before they are assigned to work in the coun- categories of health workers - namely, health officers, try.The first group in each category of students communitynurses,andsanitarians.The health was due to graduate in 1957. officers have a training period of three years, the The Ministry of Health has recently started long- community nurses have one of two years, and the term planning of health programmes, including the sanitarians follow a one -year course.All the gra- reorganization of the Ministry so as to place more duates will have one year of practice in the health emphasis on the preventive aspects of the work.
FRENCH SOMALILAND
French Somaliland lies in north -east Africa, on the Gulf of four dispensaries (32 beds); a maternity home (28 Aden.Itis bounded on the east by British Somaliland, beds); a tuberculosis centre (40 beds), and a psychiatric and the rest of the territory adjoins Ethiopia and Eritrea. It consists of an 800 -kilometre coastal strip and, in the interior, centre (10 beds).Inall,there are12 practising a series of closed valleys among plateaux and basalt ridges. physicians - i.e., one per 5000 inhabitants. There are no permanent water -courses.The area is about The health situation of the population is satisfactory 22 000 square kilometres.The nomadism of the indigenous on the whole, as there are no epidemic or pestilential population makes census- taking adifficult matter, but on 31 December 1957 the total population was estimated at 67 256. diseases.Malaria has been practically wiped out The diet of the nomads consists of milk from their herds, dates, except in some rural areas, where control is difficult and durra bread. owing to the irregularity of the rains and the nomadic The economy of the country is almost wholly dependent on movement of the people. the free port of Djibouti, the seat of government, which serves Endemictuberculosisisthe as an entrepôt for the goods carried to or from Ethiopia by the mostprominent Franco -Ethiopian Railway. disease;asystematicdiagnosis campaign started The indigenous population is semi- nomadic and exists, rather in 1954. precariously, mainly on stock -raising, except in the Ambouli Venereal diseases are almost unknown among the district, where Arabs engage in market gardening.The soil is rural populations, and no difficulty is experienced potentially fertile in some areas but water.The processing of sea -salt, of which 29 584 metric tons in case -finding and treatment in the urban areas. were exported in 1955, is the only industry in the country. The presence of malnutrition is due to the poor In 1955 -56 there were 12 primary and lower secondary schools agricultural and economic resources of the territory. and a vocational school with 41 teachers and 1248 pupils. Effortsare being made to improve local fishing Education isfree.The curriculum follows that of French schools with some adaptation to local conditions.Teaching is facilities, with a view to encouraging a wider use of in French.The indigenous languages are not written and there an available natural source of protein. are no local books. Slow progress is being achieved in the rural areas with regard to the acceptance of modern principles of Health maternal and childhealth,although more -rapid The public healthservicesareadministratively advances have been made in urban centres, where under the authority of the Governor, and technically about 50 per cent. of the women now accept qualified under the direction of the Public Health Service of the assistance in child- birth.One medical officer is in Ministry of Overseas France. A local director of charge of school health.Lessons in hygiene are public health isresponsible for the co- ordination included in the school curriculum, leading to better of the various services.In 1956 the medical and health practice in the family circle. health staff consisted of seven physicians, one phar- The recruitment of candidates for the nursing macist, one dental surgeon, two midwives, 45 nurses profession is limited to men, since women take no (male and female), two technicians and three sanitary part in public life. inspectors.Health services include the general hos- Efforts are being made to improve existing unhealthy pital at Djibouti (521 beds); a garrison infirmary housing conditions by the gradual construction of (40 beds); five dispensaries for out -patients only; more hygienic accommodation. 328 FIRST REPORT ON THE WORLD HEALTH SITUATION
IRAN
Iran is situated between the Persian Gulf and the Caspian neighbouring countries.Many internationalairlinespass Sea, bordered on land by Iraq, Turkey, the Union of Soviet throughTeheran,thusprovidingIranwithworld -wide SocialistRepublics, Afghanistan and Pakistan.Its area is connexions. 1 630 000 square kilometres.There are wide stretches of desert area, especially in the east -central and south -eastern parts of Health the country.There are two ranges of mountains: Alborz in the north (with Damavand peak, 6200 metres high), and Zagrosse About 38 years ago a Ministry of Health was esta- in the west.The Caspian coastal region is covered in woods, blished, but after a short time it was changed into a and there are also scattered woods in the west.The rainfall Department of Health under the Ministry of the is heavy around the Caspian, but very moderate in the west and east and sometimes insufficient in the south.There are Interior.In 1941, the Ministry of Health came into four distinct weather seasons in most of the country, but the being once more; until 1948 it was responsible for main temperature varies greatly from north to south; northern curative services only, but in that year a Department Iran usually has several inches of snow in winter, and the sum- of PreventiveMedicine was formed,comprising mers are moderately warm.The southern part of the country has a tropical climate. divisionsfor maternal and child health, nursing, The Government of Iran is a constitutional Monarchy, with health education,administration,healthstatistics, fourteen ostans (provinces) governed by ostandars (governors - sanitary engineering, trachoma control, malaria era- general).Each ostan is subdivided into shahrestans of varying dication,tuberculosiscontrol,venerealdiseases size.The legislative, executive and judiciary powers work control, etc.The higher authorities have recently separately.Senate and Parliament constitute the legislative power of the country; elections for Parliament (Majlis) are held planned a reorganization of the Ministry of Health every four years, and only men over 18 years of age are entitled which is at present under consideration by Parlia- to vote. The Senators are of two categories: " elected Senators ", ment.The budget of the Ministry of Health receives and " appointed Senators ", the latter being appointed personally funds from oil revenue, which are placed at the disposal by the Shah.The executive power rests with the Cabinet, which is at present made up of 14 Ministers working under the Prime of the Planning Authority, and has also benefited from Minister and aided by two Ministers of State without portfolio. the United States Foreign Operations Mission in A census in 1956 gave a provisional population figure of Iran.The Ministry of Health has two Under - 18 944 821, of whom 1 513 164 lived in Teheran, the capital. Secretaries and four departments -general: Administra- The population is mainly Aryan, and in places -particularly tion, Health, Environmental Sanitation and Public in Baluchistan-there are remnants of an aboriginal Dra- vidian race. Assistance. In 1943, a law was passed by both Houses of Parliament The health organization in the provinces is esta- making primary education compulsory.This has helped a blished in such a way as to cover both curative and great deal to reduce the number of illiterates throughout the preventive activities, and there are 844 dispensaries country.The proportion of literate population in the cities is higher than in the rural areas. in both urban and rural areas throughout the country. Although petroleum is the chief product, the country is Of these, 545 are run by the Ministry of Health, mainly agricultural and 80 per cent. of the people depend on and the remainder by other agencies such as the the land for their living, including about four million tribal Workers' Insurance Society, the Red Lion and Sun people who are engaged in livestock production; they winter Society,oilcompanies, and theImperialSocial in the lowlands and drive their herds to the mountain highlands for the summer months. Foundation. Some progress has been made recently in developing industry. In the ostans and shahrestans, the chief medical Apart from petroleum, the principal industries are carpet officers are fully qualified physicians; in rural areas weaving, cotton spinning and weaving, wool spinning and they are behdars (assistant medical officers with four weaving, the manufacture of jute sacks, silk goods, sugar and cement production.There are substantial mineral deposits years' medical training). relatively undeveloped.The principal exports are heavy oil, A law has recently been passed whereby hospitals and petrol, gum, dried fruits and nuts, caviar, hides and skins and dispensaries throughout the country under the and carpets.The imports consist mainly of cotton and woollen direct control of the Ministry of Health are to be fabrics,tea,sugar,motor vehicles,industrialmachinery, run by the municipalities concerned, which will have chemicals and pharmaceutical products. A large tonnage of shipping enters the ports on the Persian responsibility for the curativeservices under the Gulf; in the Caspian ports the tonnage is much smaller. A few supervision of the Ministry of Health.Some pro- main roads are asphalted, but most of them are not.The vincial hospitals and dispensaries have already been railway system links the Persian Gulf with the Caspian Sea, handed over to the municipalities on an experimental with branches recently opened to Mashet, Tabriz and Kashan. Two more branches -to Yezd and Isfahan-are under construc- basis. tion.A national airline connects the large provincial cities There are 159 hospitals in Iran, of which 112 are with one another and with Teheran, and also operates to government establishments under theMinistry of EASTERN MEDITERRANEAN REGION 329
Health, and the remainder belong to other agencies, teams, with the necessary drugs, are sent to different such as a university, the Royal Social Services, the areas to carry out blood tests and treatment, and Red Lion and Sun Society, the Iranian Railways, the venereal disease control centres have now been set up National Imperial Oil Company, the Army, the in six provinces. Gendarmerie and the Police.There is a total of Malaria was the most serious public health problem approximately 11 000 beds, of which 7000 are in of the country in the past, and may have been one of government establishments. the major causes of nomadism, since people moved So far as vital statistics are concerned, for the years away from infected areas to avoid sickness.It has 1953 -54 and 1955 the average birth rate was 32.2, certainly been an important cause of infant mortality and the average death rate was 8.4.Reliable data and has considerably reduced manpower and indus- for the country as a whole is dependent on completion trial productivity. A widespread control programme of surveys at present being carried out.The infant has been organized during recent years, however, mortality rate, from sampling surveys in villages near and as a result of insecticide spraying, spleen rates Teheran, Shiraz and Marvdasht and in the city of which were as high as 80 -100 per cent. in certain Shiraz, is shown as 147 with a standard. deviation areas have dropped to 2 -5 per cent., and the area of 7. of land under cultivation has quadrupled.In 1956 The number of cases of communicable diseases the control operations were reorganized to include reported to the Ministry of Health by the provincial an eradication programme beginning in 1957; plans healthofficesindicatethatdysentery,measles, have been drawn up for this programme to cover whooping -cough and typhoid are the most prevalent the period until 1961. diseases.Vaccinationagainstsmallpoxisbeing The Sanitary Engineering Division of the Ministry undertaken; sevenmillionpersonshavealready of Health has drilled 75 deep wells throughout the received primary vaccination, and itis planned to country during the period under review.Altogether continue and expand this service. 450 deep wells have been drilled within the past ten Poliomyelitis is not a serious problem in Iran, but years.Furthermore, the Planning Authority is mak- cases do occur, and visitors are advised to have a ing arrangements with contractors for the develop- vaccination. ment of a drinking -water supply throughout the Measures for tuberculosis control include plans for country. buildingtuberculosisdispensaries throughout the An important step taken by the Government has country, increasing bed capacity in sanatoria by 1000 been the banning of opium cultivation in the past a year, and continued vaccination by BCG teams. two and a half years, in spite of the fact that this The aim in 1958 is to vaccinate two million people was a source of considerable revenue to the Govern- with BCG. ment. A bill has been drafted, and is now before Since 1952 a campaign for the control of venereal Parliament,toreviseprevious legislation on the diseases has been in progress;specially equipped subject in the light of this new development.
IRAQ
Iraq extends from Turkey on the north and north -east to the ful in some years.The principal exports are crude petroleum, Persian Gulf on the south and south -east, and from Iran on cereals, dates, raw wool, and cotton.The imports are mainly the east to Syria, Jordan and Saudi Arabia on the west and iron and steel, machinery, motor cars, piece -goods, sugar and tea. south -west.It has an area of 444 442 square kilometres.It Primary education is free and compulsory from 6 to 12 years runs approximately from 37° to 48° east and from 30° to of age but attendance has not yet been enforced.Intermediate 37° north, and is traversed by the rivers Tigris and Euphrates. and secondary education have been free since 1946.The There are three main geographical regions: the highlands of the general educational level is moderate but no exact figures on north and north -east; the broad central plain between the rivers; literacy are available.The position of schools in 1955 was: and the steppe and desert in the south and west.The climate is pre -school and primary, 1549: secondary 196; technical, 11; continental and the humidity is low except near the Persian Gulf. teacher training, 10; and higher schools, 12. A university is The population at the 1957 census was 6 538 109.The main being established at Baghdad to include the existing colleges of occupations are agricultural and pastoral but there are recent arts, science, engineering and medicine.In addition there are developments in industry.Iraq will be capable of supporting colleges of law, commerce, and economics a higher teachers' a much greater population when irrigation is extended.Apart training college, and the Tahrer College for Girls.All education from the valuable revenue to be derived from oil, the wealth of in Iraq is free, except for a few private schools. the country depends on agricultural development. Two harvests At the end of 1956 there were 2044 kilometres of railway can be gathered each year, and wheat, barley, beans, rice, dates in Iraq. A metre -gauge line runs from Basrah at the head of the and Indian corn are the chief crops. Cotton -growing is success- Persian Gulf to Baghdad (669 kilometres), and thereisa 330 FIRST REPORT ON THE WORLD HEALTH SITUATION standard gauge line from Baghdad to the Syrian border which only 10 hospitals with a totalof approximately links up with the Syrian system.Some 8000 kilometres of roads 260 beds, and about 50 out -patient departments and have been developed for vehicular traffic.Much of the money obtained from oil royalties is being devoted to improving dispensaries.At the end of 1956 there were 98 communications. hospitals, with a total of 7260 beds, many of the hospitals being well equipped, with all the necessary Health facilities.The numbersof medicalandhealth personnel in Iraq at the end of 1956 were as follows: The Minister directs the general policy of the Ministry of Health and is responsible for general Doctors 1027 supervision of the staff; he may order official notices, Pharmacists 305 resolutions and instructions to be issued, their en- Health officials 386 Dentists 86 forcement being under his supervision.The head- Nurses 797 quarters of the Ministry of Health consists of a Midwives 769 Directorate -General of Health, an Inspectorate -Gene- Dressers 1309 ral of Health (both headed by physicians with the X -ray technicians 85 status of Director -General), and the Minister's private secretariat.The Directorate -General of Health in- In spite of this increase in the number of institutions cludes the following sections: judicial affairs; accounts; and personnel, more are still needed, and the demand personnel;archives;correspondence; international of the public exceeds the supply. health; and statistics. In the past, the health administration paid more The following Directorates -General are also attached attention to curative than to preventive services, to the Ministry: the Faculty of Medicine; medical and little was done in public health and preventive services; preventive medicine; and medical supplies. medicine.Since the end of the war, however, in- The Faculty of Medicine is headed by a Dean, who is creasing emphasis has been laid on preventive and responsible for the organization and administration control measures, and many plans have been drawn of all institutes and schools attached to the Faculty. up and put into operation with the help of experts The other Directorates -General are headed by phy- from WHO and other health agencies. sicians with the status of Director -General and have The five -year plan includes provision for a large the following functions : medical training centre in Baghdad, for which more (1)Medical services - in charge of all curative than16.5millionIraqidinars (US $46 205 545) matters, and all curative establishments and institutes have been allocated.This will be in the nature of a appointed by the Minister, with the exception of " medical city ", grouping together the schools of those mentioned in (2); medicine, pharmacy, dentistry and nursing, with all (2)Preventive medicine - in charge of all pre- necessary facilities, including laboratories, a research ventive activities to maintain public health and the centre and a large hospital with about 1000 beds. control of epidemic and endemic diseases, and of The Government has given the utmost attention all institutions engaged in these activities; to improving the standard of health of the inhabitants of rural areas, and legislation is at present under (3)Medical supplies - responsible for the admi- consideration to provide for yet further improvements nistration, organization, storage, importing and dis- in the health, social and educational conditions of tribution of medical and technical substances, furniture these areas. and other supplies required by the Ministry and its Some ten years ago, fellowships and study leaves Directorates - General. were granted by the Government to many medical The health administration in each liwa (province) officers to enable them to study and specialize in is in the charge of a physician with the status of Chief different branches of medicine. A number of doctors Medical Officer, who is responsible for the health have also studied and specialized at their own expense, services in his liwa under authority delegated to with the result that there are now quite a number him by the Minister. of Iraqi medical specialistsin such branches as According to available records, thirty years ago surgery,paediatrics, gynaecology, and ophthalmo- Iraq had only 75 doctors, most of them foreigners, logy. EASTERN MEDITERRANEAN REGION 331
ISRAEL
Israel lies on the western edge of Asia and at the eastern end Director -General is the official actually in charge of of the Mediterranean.Its neighbours are Lebanon on the the Ministry of Health.Under him are three Assistant north, Syria on the north and east, Jordan on the east, and Egypt on the south.The area is estimated at 20 678 square Directors -General, who are in charge of hospitals, kilometres. regional services and administration.The various There are four main regions: the hill country of Galilee, departments of the Ministry deal with epidemiology, Judaea and Samaria, which rises in places to 800 and 1200 metres; vital and health statistics, tuberculosis and venereal the coastal plain from the Gaza strip to north of Acre; the Negev, a triangular semi- desert region; parts of the Jordan valley, diseases control, malaria eradication, sanitation, public including Lakes Hula and Tiberia, and the south -western corner health laboratory services, maternal and child health, of the Dead Sea.The climate is similar to that of Lower mental health, dental health, nursing, health education, Egypt.The summer is hot and the rainy season is in the and training of health personnel. winter. The Ministry maintains six district health offices The population at the 1948 census was 785 678.The est- imated population in 1953 was 1 649 342; in 1955, 1 767 783; and 14 local health offices.It is the declared policy in 1956, 1 851 046, and at the end of 1957, 1 975 354. of the Ministry to hand over these offices to the regional The country is divided into six districts.Local authorities and local authorities as soon as they are ready to take exercise their powers mainly through by -laws approved by the the responsibility.There are as yet no fully- fledged Ministry of the Interior. health departments in the charge of regional and local Israelis mainly an agricultural country.The variety in climate permits the cultivation of many different kinds of crops. authorities, although some municipalities and local Oranges and other citrus fruits are grown in large quantities in authorities have their own sanitation, school health the coastal plain; olives are cultivated and the oil is used for food and maternal and child health services.Two of and for making soap.The main winter crops are wheat and the major voluntary health agencies also conduct barley, and various kinds of pulses, sorghum, millet, maize and sesame are produced in the summer.Potatoes can be grown limited activities in preventive medicine and public in autumn and winter.The production of eggs and milk has health. been greatly increased.The critical factor in food production In order to meet the needs arising from continuous is the supply of water for irrigation; new deep wells have been immigration and the steady increase in the popula- dug and a plan to bring water to the Negev from the Jarkon river is nearly completed. tion, the Israeli health services are being expanded. The chief industries, in addition to citrus fruits and their The staff of the Ministry of Health increased by some by- products, are manufactured food products, pharmaceuticals, 20 per cent. -from 3960 in January 1954 to 4889 at textiles and clothing, light engineering and the assembly of motor the end of 1956. cars and trucks.Citrus fruits and their by- products, polished Hospital facilities for chronic diseases were almost diamonds, artificial teeth, semi -finished textiles and pharma- ceutical drugs are exported, whereas foodstuffs, crude oil, ma- non -existent in the country a few years ago.At the chinery, iron and steel manufactures and chemicals are imported. end of 1950 there were only 0.11 beds for chronic Elementary education is compulsory for all children from 6 diseases per 1000 of the population.This rate in- to13years. A unified State -controlled elementary school creased to 0.48 at the end of 1953 and reached 0.99 at system was established in 1953 with a provision for special the end of 1957. religious schools.Many high schools in towns are private; some The hospital care of mental patients are maintained by municipalities, and some are administered has also expanded from 1.62 beds per 1000 population by teachers'co- operativesorbytrustees. The Hebrew at the end of 1953 to 2.02 at the end of 1957.Several University in Jerusalem had 523 professors and 2958 students new hospitals have been opened by the Ministry of in 1954 -55; in the academic year 1957 -58 there were 739 pro- Health or by voluntary agencies. In 1954, the National fessors and 4014 students. A new university was opened in 1955 near Tel Aviv.The Weizmann Institute of Sciences at Insurance Institute started its activities covering matern- Rehovot is engaged in pure and applied research. ity insurance, labour accidents insurance and old -age Israel's merchant navy in 1954 had 31 vessels aggregating over insurance.In 1955, 1 223 561 persons, and in 1956, 119 000 tons.Israel State Railways began operating in 1949, 1 276 771 persons, including their dependants, were serving the more important cities of the country, and in 1957 members of the three main sickness funds of the country. there were 611 kilometres of broad gauge line.In 1954 there were about 2007 kilometres of asphalt roads.There is a national The only medical school in Israel is that of the air company which operates international flights, and the country Hadassah Hebrew University inJerusalem.The is also served by several international airlines. number of students attending in 1956 -57 was 376, and 72 students graduated during the year, as against Health 64 in 1955 -56.Schools of dentistry and of pharmacy have been established in connexion with the Medical The Minister of Health is a member of the Cabinet School.The curriculum of the Medical School has and responsible to the Knesseth (parliament).The been revised with the object of introducing the preven- 332 FIRST REPORT ON THE WORLD HEALTH SITUATION tive and social aspects of medical work at the begin- Although the Ministry of Health still spends more ning of undergraduate medical education.Students than three -quarters of its budget on medical care, are required to perform part of their practical work including hospitals, there is a slow but notable increase in health centres, district health offices,well -baby in expenditure on public health work.During the clinics, etc.Increased stress is also laid during the period under review the number of well -baby clinics lectures on the modern trends of comprehensive health increased from 357 to 518, and the first four health care and the role of the general practitioner.Plans centres were opened, affording comprehensive health for the establishment of a School of Public Health are services including home nursing. An Officefor under discussion. A limited number of medical per- Health Education of the Public was set up in 1956 at sonnel in key positions were enabled to study at the Ministry's Headquarters in Jerusalem to direct public health schools abroad. educational activities at the regional and local levels There are 12 nursing schools providing three years' and to prepare and distribute educational materials. training.To make up for the shortage of qualified A number of other achievements were reported nurses, courses of 15 months' duration are held for during the period under review.As regards tuber- auxiliary nurses.There are also four schools for culosis control, screening of the population by means paediatric nurses.The number of nurses per 1000 po- of miniature x -ray photography and BCG vaccination pulation was 3.3 in 1955. were carried out extensively.The control measures There is no school for sanitarians, but intensive basic taken have made it possible to reduce the number of and advanced courses for sanitarians were held during hospital beds, in spite of the continuing immigration. the period under review.In a Public Health Training The tuberculosis mortality rate dropped from 9.1 in Centre recently opened at Sarafand, the main emphasis 1954 to 6.0 in 1956, per 100 000 of the Jewish popula- is on the training of sanitarian. A school for physio- tion; active cases reported were 80 in 1954, 67 in 1955 therapists was established in 1954. A training school and 54 in 1956 per 100 000 of the Jewish population. for occupational therapists with a three -year curriculum In order to combat the serious poliomyelitis epide- is operated jointly by several health agencies, including mics of recent years, the Ministry of Health established the Ministry of Health.There are several schools for a laboratory, which began to produce polio vaccine laboratory workers, and courses for x -ray technicians early in 1956. are held regularly. The Ministry of Health provides for treatment for The birth rate was 29.2 in 1954, 29.2 in 1955, and all cases of venereal disease, and progress was reported 28.8 in 1956.The death rate was 6.8 in 1954, 6.1 in in the control of syphilis.Control measures have also 1955, 6.6 in 1956, and 6.5 in 1957; the infant mortality been taken to prevent the spread of bilharziasis.The rates in 1954, 1955, and 1956 were 39.8, 37.3 and 40.3 malaria eradication programme is stated to be well respectively.Duringthesameyearstherehas under way.The number of cases dropped from 302 thus been a natural increase of 22.4, 23.1 and 22.2 per in 1954 to 45 in 1956.During the period under review 1000 population. some 3000 cases of ringworm of the scalp and 5000 cases For the Jewish population, the birth rate in 1956 was of trachoma were brought to treatment annually. 26.7 (26.1 in 1957), the death rate was 6.3 (6.2 in 1957), The close network of maternal and child health and the infant mortality rate was 35.6 (33.4 in 1957). centres is a special feature of the country's health Life expectancy at birth in 1956 was 68.3 years for services.Over 60 per cent. of all pregnant women males and 71.7 for females.The main causes of are under medical supervision in these centres from death in the Jewish population were diseases of the the fifth month of pregnancy.More than 95 per cent. heart and circulatory system, malignant neoplasms, of all pregnant women are admitted to hospital for external causes, bronchitis and pneumonia, and gastro- delivery.Infant care and school health services are enteritis.Prematurity also figures among the more well developed.Over 90 per cent. of all school- important causes of death.Bacillary dysentery, scarlet children in elementary schools and 50 per cent. in fever, diphtheria, infectious hepatitis and salmonel- secondary schools of different types are under medical loses are considered the most important communicable supervision. diseases; poliomyelitis is also mentioned as a serious The main problem as regards mental hygiene is the public health problem.Thereisno louse -borne lack of accommodation for mental patients.Progress typhus in the country but endemic murine typhus still reported in this field includes the introduction of occurs in some sections of Tel Aviv and Haifa. occupational therapy, the establishment of a special Louse -borne relapsing fever is also absent, but a small institution for the rehabilitation of mental cases, the number of cases of tick -borne disease are reported segregation of tuberculous mental patients, the creation annually. of mental health clinics for adults, a child guidance EASTERN MEDITERRANEAN REGION 333 clinic, and a psychiatric consultant service for delin- a constant check on water resources.Bacteriological quents. A ward for drug addicts was opened in 1956 water examinations are a matter of routine, and water- in one of the State hospitals. borne epidemics are rare.Methods of sewage disposal Occupational health falls within the competence of vary in different parts of the country.Sewage is being the Ministry of Labour.Laws governing the pro- used increasingly for agricultural purposes.Long - tection of young workers, safety control and industrial range plans for sewage -disposal systems have been hygiene were promulgated during the period under initiated. review.There has been a growing tendency towards A special committee has been set up by the Govern- the establishment of medical departments in the more ment to explore the possibilities of organizing a system important industrial enterprises. A limited number of national health insurance.As another step towards of industrial nurses are employed by the Sick Fund of the unification of the health services, discussions relat- the Federation of Labour. ing to the co- ordination of the various health institu- In co- operation with the Central Water Authority tions concerned with mental health and chronic the sanitary engineers of the Ministry of Health keep diseases have been initiated.
HASHEMITE KINGDOM OF JORDAN
The Hashemite Kingdom of Jordan is bounded by Syria, Iraq, as phosphates and other products, and its imports, are routed Saudi Arabia and Israel.It has two divisions, which were through this port. united in 1950: Western Jordan, which includes the districts of Hebron, Jerusalem (part) and Nablus; and Eastern Jordan, Health which includes Ma'an, Kerak, Balqa, Ajlun and Amman. Western Jordan is fertile but severely eroded; Eastern Jordan The health and medical services of the country are is a fertile mountainous area and, like the eastern half of the directed by the Minister of Health, who is assisted by Jordan valley, is productive.The area is 96 610 square kilo- an Under -Secretary of State for Health; an Assistant metres. Under -Secretary; and a Director and a Supervisor The populationin1957 was1 538 028, compared with 1 329 174 in 1952, with a density of 16 per square kilometre. of Health Projects.In addition, there are directors Most of the population is engaged in agriculture and sheep- and of the following departments:internalmedicine, goat- rearing. surgery,ophthalmology,otolaryngology,malaria, The economy is primarily agricultural, but phosphate mining tuberculosis, laboratory services, blood transfusion is being expanded, and there are proposals for exploiting the rich potash resources of the Dead Sea. services, and of the broad divisions of mental health There has been a perceptible improvement in the general and maternal and child welfare.Other staff consist level of education, owing to the fact that education in govern- of: six District Senior Medical Officers; a sanitary ment primary and secondary schools is given free to all classes engineer;the Chief of Pharmacies Division;the of the people.In 1957 there were 840 primary schools, with a Chief Accountant; and the Directress of the Nursing total of 208 501 pupils (139 622 boys and 68 879 girls), and 360 secondary schools with a total of 44 112 scholars (35 798 boys School.The total number of staff in 1950 was 149; and 8314 girls).There were six occupational schools, with a by 1957 it had increased to 1469, including 77 medical total of 704 students, and three agricultural schools, with officers employed according to their various specialities, 201 students.This gives a total number of schoolchildren and and 367 nurses. students of both sexes of 253 518.There were also six teacher - training schools. There are 21 government hospitals, with a total On matriculation, some students complete their university capacity of 1266 beds, and 24 private hospitals, with education outside the Kingdom -in Lebanon, Egypt, Syria, a total capacity of 1389 beds.It is planned to group Iraq, the United States of America, or other international together all the hospitals in Amman in one place; the university centres.In 1957 almost 3000 students were following university courses. Tuberculosis Hospital, the Surgical Hospital and the There are all- weather asphalted roads in Jordan, linking the Nursing School and its hostel are already situated towns and villages together, and contributing to the economic close to one another, and the following hospitals will and agricultural revival of the country.The Hedjaz Railway also be moved to the same site: the Eye Hospital, the runs from Damascus in Syria through Jordan to Ma'an; this Ear, Nose and Throat Hospital, the Children's Hospi- line originally ran as far as Medina in Saudi Arabia.There is also a sub -line from Ma'an to Ras El -Nagb, from which an tal,the Maternity Hospital, the Internal Diseases asphalted road continues to Aqaba, the only sea -port in the Hospital, the Infectious Diseases Hospital, and the country, on the Gulf of Aqaba.The country's exports, such Midwifery School. 334 FIRST REPORT ON THE WORLD HEALTH SITUATION
The availablevitalstatisticsfor the four -year tinuous months), and graduates are employed in period 1954 -57 are as follows : government and private hospitals.The midwifery 1954 1955 1956 1957 course is of two years' duration (18 continuous months), Birth rate 38.4 40.7 37.6 39.3 and graduates are employed in maternal and child Death rate 10.4 9.3 8.4 8.4 health centres and maternity hospitals. Infant mortality rate . . 89.0 72.8 73.6 69.3 Two government laboratories are attached to the In 1957 there were 136 clinics.So far, 23 MCH Ministry of Health, one in Amman and one in Jeru- centres have been established, and the Ministry of salem.These laboratories have a good number of Health is planning to set up 30 new centres in various specialized doctors and chemists.The government districts. laboratory in Jerusalem prepares antityphoid, anti- Two main antituberculosis centres, and 29 malaria rabies and antismallpox vaccines.There are also control centres for supervision of the malaria eradica- four laboratories in four of the district government tion programme in the country have also been esta- hospitals, and the Ministry of Health is planning to blished. establish a small laboratory in each of the government There are two nursing schools and one midwifery hospitals.Most of the hospitals also have x -ray school.The nursing course lasts four years (36 con- sections.
LEBANON
The Republic of Lebanon lies on the eastern coast of the vities were extended, particularly to the provision Mediterranean, bounded by Israel on the south and by Syria of free medical care for the needy. on the east and the north.It is about 195 kilometres from north to south and 45 -55 kilometres from east to west, with a The Ministry of Health in its present form is com- total area of 10 400 square kilometres.Part of the inland posed of three Departments, dealing respectively range resembles steppe country; about half the country has an with administration and finance, technical matters altitude of over 900 metres.The climate is hot in summer and and medical care.These Departments are supervised rainy in winter.The capital of Lebanon is Beirut. by a Director- General. For administrative purposes, the country is divided into four provinces and 24 counties.The population at mid -1954 was Apart from general administrative and financial estimated at 1 383 000 with a density of 133 per square kilometre, work, the Administration and Finance Department and at the end of 1956 it was estimated at 1 500 000. also deals with health legislation.The Technical The economy is primarily agricultural, but in 1954 there Department deals mainly with matters related to were also 2518 industrial establishments with 25 583 workers, the majority employed in food -processing, hotels, quarrying, public health, and comprises the following 11 sections : and wood and metal work.About half the population is sanitary engineering; pharmaceutics; preventive med- urban. icine and control of communicable diseases; maternal Elementary education is compulsory but there are not yet and child health; school health and health education; enough schools or teachers for this requirement to be fully vital and health statistics; control of the medical effective.For higher education there are in Beirut a French University, an American University, and a Lebanese National profession; dental hygiene; quarantine; international University (which is chiefly a teachers' training college). health affairs, and the Library.The Medical Care Beirut is the largest and busiest port of the country, and is Department is in charge of the central and regional also an important centre of international air traffic.The rail- government hospitals and dispensaries and also of the way system connects Lebanon with Syria and thence with Mosul and Baghdad in Iraq, and Ankara and Istanbul in medical care services for government employees, the Turkey.The main roads are good. poor and indigent, and workers in industry and in private employment.The Department is also carrying Health out studies in co- operation with the Ministry of Social In itsearly days, the health administration of Affairs, with a view to the organization of a medical Lebanon was a Directorate of Health consisting and hospital insurance system for the whole country. of a few physicians, nurses and sanitarians, whose At the local level, health units represent the Ministry main activities were limited to curative medicine in of Health in each county. Each of these 24 units is the different dispensaries scattered throughout the staffed by a physician, a public health nurse and a country.During the second half of the French sanitarian, and their activities include public health, Mandate, a Ministry of Hygiene and Public Assistance socialhygiene,sanitaryinspectionand medical was established; more staff was appointed and acti- examination of needy persons and of certain other EASTERN MEDITERRANEAN REGION 335 groups, such as industrial workers and the employees Intensive malaria control operations over a number of food -handling establishments. of years made it possible to enter the eradication The health services budget in 1957 amounted to stage during the period under review. A special 8.6 million Lebanese pounds (US $2 687 500), or malaria control office has been set up, and co- ordina- 5.06 per cent. of the total national budget.Almost tion with the malaria eradication programme in half of the health budget was set aside for health Syria is being worked out. programmes in the rural areas, not including the The Ministry of Health is aware of the importance normal running costs of the municipal health services; of health education of the public and a department the per capita expenditure from the central budget has been established within the Ministry for this was estimated at 3.84 Lebanese pounds (US $1.20), purpose. and from the regional budget at3.35 Lebanese Progress in the period 1954 -56 includes the creation pounds (US $1.04). of a central public health laboratory; the building of In 1956 the total registered number of deaths in a new leprosarium; the provision of new hospitals; Lebanon was 8286, with 753 infant deaths.Registra- theestablishmentof arehabilitationcentrefor tion of births and deaths is not complete at present and handicapped children; and the opening of a maternal efforts are being made to improve it.Birth reports and child health centre.Greater stress was laid were issued by the Ministry of Health in 1957 for the on the development of the mental health services, first time. and two important mental hospitals were provided Records from some 45 government and private with more beds, better equipment and a larger staff. hospitals show a total of 42 663 in- patients admitted There are two schools of medicine in Beirut, the in 1955, and 48 429 in 1956, government dispensaries French Faculty and the American University, with and clinics in 1956 provided the following out -patient a total of approximately 400 medical students between services in 1956: them each year, of whom some 75 per cent. are Number Lebanese.About 50 doctors graduate from these Type of dispensary or clinic of visits two schools annually.Both schools aresteadily Dentistry 11281 Maternal and child health 7209 extending the scope of theiractivities. A Chair Paediatrics 5403 of tuberculosis has been created in the French Faculty, Venereal diseases 4023 and bothfacultieshavecreated departments of Gynaecology and obstetrics 3644 preventive medicine, and have a system of visiting Ear, nose and throat diseases 3554 professorships in various specialties.Both provide Internal medicine 2724 courses in industrial hygiene. Diseases of digestive system 1503 The School of Public Mental disorders 644 Health at the American University of Beirut also Tuberculosis 421 trains personnel for public health administration, sanitary engineering, health education of the public, Communicable diseases reported for the year 1956 health statistics, public health nursing and laboratory included typhoid and paratyphoid fever (462), tuber- work. culosis of the respiratory system (266), diphtheria There are eight schools of nursing, and one (135), acute bacillary and amoebic dysentry (131), school which provides special training for psychiatric andmalaria(108).An outbreakofsmallpox, nurses. introduced from abroad in December 1956, caused Fellowships are made available to about 70 per cent. 192 cases and 46 deaths, but was brought under of the medical staff of the Ministry of Health for spe- control by February 1957 as a result of the active cialization, and nurses of the central administration measures applied. are also sent abroad for special training.
UNITED KINGDOM OF LIBYA
The United Kingdom of Libya, on the Mediterranean coast the Sahara desert.There are no rivers and rainfall is precarious. of Africa, is bounded on the east by Egypt and Sudan, on the The climate is that of desert and semi -arid areas with a small south by French Equatorial Africa and French West Africa and strip of the Mediterranean type. on the west by Algeria and Tunisia.It consists of the three The population at the 1954 census was 1 091 830, with a provinces of Tripolitania, Cyrenaica and the Fezzan, and has an density of 1 per square kilometre and showing an annual rate of area of 1 759 540 square kilometres. increase of 1.39 per cent.Tripoli (142 000) and Benghazi Vast sand and rock deserts, almost completely barren, occupy (60 000) are the joint capitals; the other main cities are Misurata, the greater part of the country, and its southern part lies within Horns Cussabat, Derna, Barce, Tobruk and Sebha. 336 FIRST REPORT ON THE WORLD HEALTH SITUATION
The three provinces are each administered by a Governor, to provide one centre for every 6000 people in Cyre- assisted by an executive and a legislative council, three- quarters naica, one per 2000 in the Fezzan and one per 8000 in of whose members must be elected. In the coastal zone-an area of about 44 600 square kilo- Tripolitania.The majority are staffed only by a male metres -date palms, olives, cereals, figs, grapes, oranges and nurse, though in Cyrenaica most of the centres are other fruit are grown.The more important industries of Tripoli - visited by a doctor once a week.It has been estimated tania and Cyrenaica are sponge fishing, tunny fishing, tobacco that a total of 173 health centres will be needed in growing and processing, dyeing and weaving of local wool and Libya, and the Government, with the help of economic imported cotton yarn. In recent years there has been striking progress in education aid from the United States of America, has devoted in Libya.There are 433 elementary schools with 73 158 male US $40 000 in 1956 to refurnishing and equipping pupils and 16 400 female pupils, 37 preparatory schools and the health centres.US $3000 were allocated in the eight secondary schools with 5271 scholars, four teacher -training same year to give refresher training to the male nurses. colleges with 1283 male and 285 female students, and eight technical schools with 722 students.Private schools include Itis proposed in the first instance to rehabilitate 25 kindergardens, 69 elementary schools, and eight secondary 153 such centres. schools, with 5672 boys and 5158girls.There arealso The lack of trained Libyan medical and health 693 religious schools, with 20 609 students. personnel is a problem.With the assistance of WHO So far as communications are concerned, the Tripolitanian and UNICEF, a school for female nurses was estab- Railway serves the districts of Tripoli, Tellil, Zuara, Azizia and Tagiura.In Cyrenaica, the railway covers the lines Benghazi - lished in Tripoli in 1956; in both Tripoli and Benghazi, Barce and Benghazi -Soluch.There are about 3830 kilometres training centres have been set up to train maternal of carriage roads, on which there are bus services.Inland, the and child health auxiliaries; and a federal school was principal means of communication are the caravans, which established in Benghazi in 1956 to train health assis- follow long -frequented routes.Benghazi is linked by air with Cairo, Tripoli and Malta. tants and sanitarians who will work in the health centres in rural areas.The course is of about three years' duration and is available to secondary school Health graduates from all three provinces. The Minister of Health is responsible to Parliament Students training abroad include 48 medical students, on all matters of health, and deals with interna- five pharmacy students, seven in veterinary medicine tional health questions and with foreign and inter- and two in dentistry, as well as a number of students national bodies offering assistance to Libya in the in auxiliary health branches. medical field.As technical adviser to the Minister The most important communicable diseasesin there is a Director -General of Health, who is assisted Cyrenaica and Tripolitania are pulmonary tuberculosis by a Deputy Director -General. and trachoma. A BCG vaccination campaign, which is The health department of each of the three Provinces now a part of the general activities of the health service, is autonomous as far as the planning, organization and was initiated with the help of WHO during 1953. administration of health services within the Province A tuberculosis survey, which isbeing conducted are concerned.Each Province has a Nazir of Health throughout the country, is expected to be completed who has ministerial functions and, in that capacity, is during the first half of 1959. a member of the Executive Council of the Province. A malaria survey is being made in the three Pro- Each Nazir of Health has a Director of Medical Ser- vinces under the auspices of the malaria eradication vices as technical adviser, and in Cyrenaica and Tripo- programme. litania there is also an Assistant Director of Medical Libyan- American Public Health Joint Services, esta- Services.At the local level there are district medical blished in 1955, are organizing various health projects officers appointed by the Nazirate of each Province to improve hospitals, ambulatoria, laboratories and to supervise the local health services, which consist community health services throughout the country. of " ambulatoria ", or small health centres.In the Courses in health education were started in 1953, district towns a doctor is in charge of the service, in Tripoli, for women school -teachers, for women while in rural areas male nurses are responsible for the trainees at the maternal and child health centre at Suk- work. el-Giuma, and for students at the school for assistant The development of the health centre system began nurses.Hygiene lessons were introduced intoall in Libya about 30 years ago, and in 1954 it was planned grades of schools during the scholastic year 1956 -57. EASTERN MEDITERRANEAN REGION 337
PAKISTAN
Pakistan consists of East and West sections, situated on each services and placed them under a Director of Health side of the base of the Indian Peninsula.West Pakistan touches Services, East Pakistan.Various health conferences the Himalayas and the Hindu -Kush mountains in the north and descends from high Pamir to the Arabian Sea.East Pakistan were held, and in 1951 a draft five -year plan was in- lies between West Bengal and Assam and Burma, with the Bay augurated to deal with such aspects of national of Bengal in the South.The combined area is 944 824 square public health as nutrition, medical education, research, kilometres. ruralhealthservices,etc.A country -wideanti - The population at the 1951 census was 75 842 162, with a mosquito programme and a BCG vaccination pro- density of 85 per square kilometre.The general educational level is rising steadily.At the time of the 1951 census it was gramme were also approved. estimated that about 19 per cent. of the people were literate. The various personal healthservices,including In the federal capital, Karachi, which now has a population of maternal and child health, have been developing over one million, and in several other cities, the percentage of since 1947, but a great deal of leeway has had to be literates is between 30 and 40, reaching over 60 per cent. in some of the towns of East Pakistan. made up.In part of West Pakistan, where health Agriculture is the largest industry and 80 per cent. of the services were relatively well developed, before 1947 people are directly or indirectly dependent on itfor their there was only one hospital bed for every 2309 persons, livelihood.The main crops are rice, wheat, cotton, jute and while in the entire sub -continent there was only tea.In recent years, however, there has been a gradual increase one midwife for every 60 000 and only one health in emphasis on heavy industries.The Government has estab- lished a special Industrial Development Corporation, as well as visitor for every 400 000 persons. a Small Industries Corporation to look after the development At the time of independence only three medical of small and cottage industries.In addition a few technical colleges existed in Pakistan (Lahore, Karachi and training institutes have been set up. Dacca) and only one was producing medical graduates. The Pakistani Railways comprise two separate systems: the North -Western Railway in West Pakistan has a length of 8587 Since then, five more have been established, in Lahore kilometres, and the East Bengal Railway covers 2748 kilometres. (the Fatima Jinnah Medical College for Women), Pakistan has over 100 000 kilometres of roads. A road develop- Hydrabad, Multan, Peshawar and Chittagong.To ment programme has permitted of considerable improvements in make up for the lack of teachers, medical graduates construction.In 1947, Karachi and Chittagong were the only have been sent abroad regularly for further training. ports in Pakistan.The port of Karachi has developed greatly since then and now serves the entire region of West Pakistan and An institute for post -graduate training in basic medical the neighbouring country of Afghanistan - handling all types of sciences - anatomy, physiology, pharmacology, path- cargo.The port of Chittagong has recently been developed, ology, bacteriology and biochemistry - is scheduled and the other port in East Pakistan is the Chaina Anchorage, to commence functioning in early 1959. which was opened to traffic in 1950.Inland water transport plays a considerable part in the economic and commercial life With the departure of Indian staff from hospitals of East Pakistan, where there are over 4290 kilometres of after independence, there was a grave shortage of navigable waterways. nurses,midwivesandauxiliarypersonnel.The In Karachi and Dacca there are international airports, the Central Government set up schools of training, first latter being the centre of air services in East Pakistan.Other at Lahore in 1950, and subsequently at Karachi, airports have also been developed, such as those of Chittagong and Lahore. A national airline operates services to Europe, Dacca and Peshawar.Since then a college of nursing and various other international airlines make Karachi one of has been established, which acts as a central educa- their important ports of call. tional institute for training sister -tutors. A Nursing Council was constituted in Pakistan in 1949 in order Health to maintain uniform training levels.The Nursing Adviser is attached to the Office of the Director - In 1949 the Central Government amalgamated its General of Health. medical and public health departments and placed The latest vital statistics available (for the year 1952) them under the control of a single officer designated as are: birth rate, 22.5; death rate,11.5; and infant Director -General of Health, who also has the status mortality rate, 103.5. of Joint Secretary in the Ministry of Health.The Malaria is still one of the major health problems in provinces (at that time, Punjab, Sind and the North - Pakistan.About 60 million peoplelivein areas West Frontier, but now constituting a single province, where the disease is prevalent and some 30 per cent. West Pakistan) followed this arrangement and each of the total population are affected each year. Assisted appointed a Director of Health Services at the pro- control schemes have been in operation since 1951 vincialheadquarters.The GovernmentofEast and are making steady headway.By the end of 1957 Pakistan has also amalgamated its medical and health more than 37.5 million people were protected by 338 FIRST REPORT ON THE WORLD HEALTH SITUATION residual spraying. A Malaria Institute first set up sources.Itisthus a programme of partnership in Karachi in 1947 was removed to Dacca in 1952, between the people on the one hand and their own with a branch remaining at Karachi. welfare government on the other. Tuberculosisisthe second great public health The Programme aims at assisting the villagers to problem of the country. A control and demonstra- plan and carry out self -help schemes to improve their tion centre has been established in Karachi to train standard of living,reduce sickness and promote medical, nursing and technical staff.In 1949, BCG healthintheseareas by undertaking economic, vaccination was started by the Government, and by social and public health development.The plans the end of December 1957 about 22.7 million persons under the Programme include,inter alia,schools, were tuberculin- tested and 7.9 million were vaccinated dispensaries, health and community and maternity with BCG in the two zones.The programme is centres, water -supply schemes, etc. being further extended in East Pakistan and additional In order to fulfil the above objectives and to help teams have been recruited to increase tuberculin - the villagers in tackling and solving their problems, testing. multi -purpose workers, both male and female, are A Health Education Bureau, established on a modest being trained for a period of one year in the nine scale in the Office of the Director -General of Health well- equipped training institutes (to which two more in Karachi, has been in operation since 1952 and has will be added soon), and sent out to the villages to been disseminating health knowledge in the country, work with the various communities.As the Pro- through the media of pamphlets, posters, leaflets, gramme iscomprehensive enough to cover most filmstrips, cinema slides,etc., on such subjects as aspects of rurallife,these workers are generally cholera, typhoid, sneezing, coughing and spitting, trained in agriculture, animal husbandry, horticulture, food for the child, venereal diseases, drinking -water, education, cottage industries, health and sanitation, rules of health, kitchen hygiene, prevention of tuber- co- operatives and home economics, withspecial culosis, cleanliness of the home, diseases caused by emphasis on application in rural areas, and a good dirty hands, etc.To expand the scope of its activities, deal of practical and fieldtraining.The multi- additional staff are being recruited. A scheme for purpose worker thus trained acts as an extension the establishment of similar bureaux of health educa- agent for all the nation -building departments, and tion is under consideration by the Government of uses the various skills he has learnt with regard to West Pakistan, while the Government of East Pakistan human relationship in individual and group motiva- has already decided to set up a health education tion to create a community spirit among the rural organization. people.The Village Aid Programme has been in One of the most important services that have been operation for about five years now, and has been organized in recent years is community development, able to put into the field 2300 village workers (including known in Pakistan as the Village Agricultural and 168 women) to work in 89 Development Areas, each Industrial Development Programme (commonly called containing about 150 villages, in both East and West V -AID).This isa programme of comprehensive Pakistan.Each Development Area is in the charge development of the rural society on the basis of self - of a Development Officer assisted by two supervisors. help through education, motivation and co- ordinated Each worker looks after some five to seven villages. efforts on the part of the people and the Government. According to the first five -year plan, 1955 -59, about The educational aspect of it consists in bringing to one -quarter of the country will be covered by the the knowledge of the rural communities their poten- Village Aid Programme during this period, while the tialitiesfor improvement through individual and whole country is expected to come under it in about community action, and in providing them with the 12 -15 years at the present accelerated pace of progress. basic skills and techniques necessary for carrying Two Academies for Village Development are being out specific tasks for the attainment of a higher set up, one in Peshawar (West Pakistan) and the other standard of living.Government assistance comes to in Comilla (East Pakistan), for the training and orienta- them in the form of technical assistance, advice, tion of officers of V -AID and nation -building depart- equipment, machinery, material or financial assistance ments, including members of the civil services of only to the extent of supplementing their local re- Pakistan and of the provincial civil service. EASTERN MEDITERRANEAN REGION 339
SAUDI ARABIA
Saudi Arabia occupies the greater part of the Arabian Penin- hospitals providing 5400 beds in five years.Among sula, with an estimated area of 1 600 000 square kilometres. the preventive units in these 39 districts, in addition It has a long coast line on the Red Sea and a shorter one on the Arabian Gulf, and is bounded on the north by Jordan and Iraq to the district health offices, there will be established and on the south by Yemen, Aden and Oman. The general in the course of five years 30 quarantine stations for contour of the country is a plateau sloping gently eastward both sea- and airports, 17 malaria control stations, from a mountain range along the west side of the peninsula five maternal and child health centres and four venereal about 15 -25 kilometres from the Red Sea coast.The mon- soon brings some rain to the south -west corner, but most of the disease control centres, one public health centre and country is true desert, with many scattered oases and some valleys one public health nursing school. that permit agriculture. Thetotalgovernmentbudgetincreased from The population, which is almost wholly Arab, was estimated 203 million rials (US $54 467 400) in 1949 to 1300 at seven million in 1952.Riad, the capital, has a population of million (US $348 806 010) in 1954, and the allocation about 100 000, Jeddah, the main port, about 200,000, and Hofuf 100 000.Many of the people are nomads. for public health purposes also increased from 1.5 Development of the oilfields in Saudi Arabia has revolu- per cent. of the total government budget in 1949 tionized the country's foreign exchange position and greatly (3 million rials, or US $804 937) to 5.4 per cent. improved the economic situation. (70 million rials, or US $18 781 862).It may be expected Education is provided for boys and young girls, and in 1952 there were 344 primary schools, 20 secondary schools, five that the five -year plan will be fulfilled if the problems technical schools, seven teacher -training schools and one higher of health personnel can be solved. school.The last- mentioned school prepares students who have The present hospital facilities in Saudi Arabia are completed their secondary education for university training as follows : in Riad, the capital, there is a new hospital in Egypt or elsewhere.With three exceptions, all schools are (600 beds) withfirst -class equipment, which was maintained by the Government. The only completed metalled road, apart from those in the established in 1956; there are also in Riad a military oilfields area, connects Mecca with the port of Jeddah, but a hospital, a chest diseases hospital, the Royal Palace new road from Jeddah to Medina was under construction in 1955. Hospital, and two private establishments.Jeddah A railway from the port of Dammam to the oilfields at Abqaiq has a general hospital with 300 beds, a gynaecology and through Hofuf to Riad was opened in 1951.There are internal air services, regular services to Cairo and Beirut, and and midwifery hospital with 100 beds, and three several international airlines call at Jeddah. private hospitals.In Mecca, a new 600 -bed hospital was opened in 1957, which is intended to replace within a few years the old hospital with 300 beds Health which is at present still functioning; there is also The Ministry of Health, with a Minister and an in Mecca a hospital (100 beds) for gynaecology and Under -Secretary, is directly in charge of the health midwifery.In each of the other important towns services of the country.Following a health survey, there is a general hospital, with about 125 beds, the Minister, in compliance with the wishes of the and in smaller towns there are dispensaries with King and the reformatory policy, has recently drawn in- patient accommodation.Since 1954 the Govern- up a detailed long -term health programme for the ment has begun to set up special hospitals for tuber- country, known as Circular No. 1 of the Ministry culosis patients, the main one being on the road of Health, Kingdom of Saudi Arabia.According between Jeddah and Mecca, with a capacity of to this programme, the Kingdom isdivided into 150 beds. the following six health areas: Eastern area; Riad In 1955 about 200 physicians were employed by area; Mecca area (including the places of pilgrimage); the Government, mostly on a part -time basis, for the Medina area; Western Coast area; and Al -Assir area. various types of health services throughout the coun- A medical officer, appointed by the Minister of try.In order to train more medical personnel the Health as the representative of the Ministry, is respon- Government has been sending studentsto study sible for the supervision of the curative, preventive, medicine and allied subjects in Egypt, and altogether quarantine and administrative services in each area. 90 students were studying there in 1955. The areas are divided into health districts with medical Malaria, tuberculosis, venereal diseases, bilharziasis, officers in charge.Within each health district there ankylostomiasis,dysentery,leishmaniasis,filariasis are both curative and preventive units providing and some other tropical diseases are common During the population with direct services.This plan calls the period under review a venereal disease control for the completion in 39 districts of a total of 75 centre with a serological laboratory has been estab- 340 FIRST REPORT ON THE WORLD HEALTH SITUATION lished in Mecca, and field surveys have been carried eluding the Najran and El Leith valleys.In 1955 out in Assir, Medina and Nejd to determine the pre- a tuberculosis survey was carried out. valence of the infection.At the same time a malaria In 1956 the Jeddah quarantine station was opened control programme was initiated, first in the Jeddah -a significant development because of its valuable area and later extended both north and south, in- service during the Mecca pilgrimage.
SUDAN
Sudan extends from thesouthernboundaryof Egypt healthservicesthroughout Sudan, including the to the northern boundary of Uganda, and from French Equa- training of local medical and health personnel.He torial Africa to Ethiopia and the north -west boundary of Eritrea and the Red Sea.There are some fairly wide uplands in the is assisted by a deputy director, an assistant director west, with one peak over 3000 metres high, but most of the of public health services, an assistant director of country is below 450 metres, with no marked physical features hospital services, an assistant director of research except the Nile.Three zones can be distinguished.The first, and public health laboratories, a chief public health in the north, is mostly desert, from the Egyptian border to Khartoum.The second, in the centre, has many streams, inspector, a principal matron, a controller of medical most of which run into the Nile.Irrigation has been well stores, a controller of accounts, a senior establish- developed and this zone is therefore the most important, econo- ment officer, and a non -medical inspector of admi- mically and politically.The third, in the south, is typically nistration. A central board of public health has Central African, with large swamps, wide stretches of savannah been established to act as an advisory body to the and tropical forest, but with some cultivation.There is a wide range of climate, from the hot desert in the north to the equatorial Minister, under the chairmanship of the Director south, where rain falls for more than half the year.The area of Medical Services.Health boards have also been is 2 505 823 square kilometres. created at the provincial and district levels.At the The population was estimated in 1957 at 10 700 000.The local level, health committees have been set up as capital is Khartoum. Port Sudan, on the Red Sea, is a well - equipped modern port. subsidiary bodiestothelocalcouncilsin some Agriculture is the chief occupation, the principal grain crop areas. being dura millet, which is the staple food of the Sudanese. Themedicalservicemaintains50hospitals, Sesame and groundnuts are other important food and export 879 dispensaries and dressing stations (providing a crops.The nomadic Arab tribes of the plains and the Negro tribes of the river and swamp country in the south depend tótal of 9606 beds), and 193 physicians.There are for their livelihood on livestock.Egyptian and American -type also 80 private practitioners, 37 qualified pharmacists cottons are grown, the Sudan -Gezira Scheme, irrigated from and 29 dentists working independently.The Christian the Blue Nile, providing most of the high quality cotton. missions also maintain local medical services. Sudan is also the chief source of the world's supply of gum The former Kitchener School of Medicine has arabic. Sudan was proclaimed a sovereign independent republic now been incorporated as a Faculty of Medicine on 1 January 1956.The country is divided into nine provinces, into the University of Khartoum, and offers a six - each under a Governor assisted by an advisory provincial council, year medical course.It also provides post -graduate except Khartoum province, which is under a Commissioner opportunities for specialstudy andresearch by and has no provincial council.The provinces are sub -divided Sudanese doctors.The annual number of graduates into 69 districts, each under a district commissioner.Local administration is now largely in the hands of statutory local from the school is reported to be 20. government authorities, which are the sheikhs and chiefs in The school for medical assistants, which was first tribal areas, and the councils in urban or advanced rural districts. established in1918,is now offering a three -year The education' system, which formerly fell into two sections course equivalent to intermediate education for the -north and south -is now being unified under the control of the Minister of Education.Arabic is taught in all government training of medical assistants.They are working schools and in intermediate mission schools; the latter were to as assistants in hospitals and are also assigned to be taken over by the Government in 1958. rural dispensaries responsible for the medical work The University of Khartoum, which is administered by an of the districts and for such public health duties as independent council and comprises faculties of arts, science, agriculture, engineering, veterinary science, medicine and law, may be delegated to them by the medical officer was given full university status in 1956. of health. A School of Hygiene was established in 1932 to Health produce Sudanese sanitarians holding the certificate The Director of Medical Services under the Minister (now diploma) of the Royal Societyof Health of Health is responsible for the organization of all (R.S.H.).Candidates are chosen from among boys EASTERN MEDITERRANEAN REGION 341 who have completed their secondary education.They The incidence of tuberculosis is not known but spend one year in Khartoum Technical Institute and the number of patients in hospitals appears to be two years in the School of Hygiene.At the end on the increase.In 1954 -55 the diagnosed incidence of the third year candidates sit for the R.S.H. examina- of tuberculosis was reported to be 65 per 100 000 popu- tion, and those who are successful are awarded the lation.An extensive campaign of BCG immuniza- Diploma in Public Health Inspection.At present tion isat present being conducted in the Upper there are 76 qualified officers who graduated from Nile Province.Tuberculosis control staff are being this School.Some of these are designated senior trained at the Wad Medani tuberculosis demonstra- publichealth inspectorsincharge of provincial tion and training centre, with a view to developing sanitation, and others (public health inspectors and domiciliary care services rendered from rural health officers) are employed by local government councils. centres.There are special tuberculosis wards in the The School of Hygiene also gives short training to central and district hospitals but all are far below sanitary overseers (sanitary assistants and sanitary the optimum need. aides), who are in charge of village sanitation under Syphilis is prevalent among the rural population the supervision of qualified officers. as well as among nomadic tribes all over the country, There are seven training schools for midwives in while gonorrhoea isessentially an urban disease. the country, one located at Omdurman for literate It is reported that successful results in the control trained nurses and illiterate district midwives, and of bilharziasis have been obtained by snail eradica- the othersixsituatedat provincial headquarters, tion measures. mainly for the training of illiterate district midwives. Malaria is the chief endemic disease in the country. The Central Nursing Council, under the control of Residual spraying with insecticides,however, has the Director of Medical Services, is responsible for proved successful in lowering the incidence in certain nursing training in the Sudan. A nursing certificate areas. is issued to candidates who qualify after a three -year Trachoma is widespread in the Sudan, particularly nursing course.There are now 15 sub -grade (first - among the young.Routine school inspections are year curriculum) and 30 complete schools, as well carried out and daily treatment given whenever as eight hostels for female nurses in different parts of possible, mainly with a view to combating super- the country.Successful candidates in the sub -grade imposed infection. schools continue theirtrainingat the provincial Kala -azar still continues to be hyperendemic in headquarters school.Ample opportunities are avail- the Upper Nile Province with bouts of increased able for certificated nurses to take higher training incidence every few years. as health visitors, staff midwives, etc., or as labora- The treatment of leprosy with sulfone drugs has tory and medical assistants, theatre attendants and given encouraging results and patients have shown so forth.In addition, a nursing college has recently increasing readiness to attend out -patient centres for been opened in Khartoum for the training of girl treatment and inspection. graduates of secondary schools.Graduates of this Other measures for the control of communicable college will receive a universally recognized diploma diseases include rat control in ports and big towns, and will be expected to be the leaders in the nursing smallpox vaccination in the western provinces and profession in the Sudan.Sudanese girls now under during the pilgrimage season, inoculation against training at the Higher Institute of Nursing in Alexan- yellow fever, together with a wide Aëdes control in dria will in due course take over the responsibility infested areas, and delousing measures for the control of nursing training in this college. of relapsing fever. Health education of the public is carried out in There are 35 maternal and child health centres health centres, dispensaries and local councils and sponsored by the Ministry of Health and conducted by public talks and the use of visual media such as by Sudanese health visitors under the direction of posters and leaflets.The introduction of 65 specially nursing superintendents. A number of simple ante- designed and equipped ambulances toservethe natalclinics have also been established in rural villages far distant from the nearest medical unit areas in the charge of district midwives, and are has also been useful in the dissemination of public likewise subjected to periodic supervision by nursing health education in regard to simple hygiene habits officers and the medical assistant of the area.All and care. examinations are given free of charge. 342 FIRST REPORT ON THE WORLD HEALTH SITUATION
SYRIA 1
Syria is bounded on the north by Turkey, on the east by Iraq, In 1946 a Ministry of Health and Public Assistance on the south by Jordan and Israel and on the west by Lebanon was created.Certain Articles of the Constitution of and the Mediterranean.The Euphrates river flows through the north -east to the boundary of Iraq.The climate is temper- Syria, which was drawn up in 1950, defined some of ate- Mediterranean on the coast and becoming progressively the responsibilities of the Government in public health. more arid inland. The central health administration in its present form The area is approximately 184 500 square kilometres.Popula- comprises a Directorate of Health Affairs, a Director- tion figures, according to the latest estimates, were 4 025 165 in 1956, with 423 832 in the city of Damascus.In 1953 the ate of Administrative Affairs, and a Directorate of country was divided into nine provinces or regions. Pharmaceutical Affairs.Departments created since The economy of Syria is essentially agricultural, most of the 1950 include maternal and child health, health educa- population being engaged in cultivation.The principal crops tion of the public, international health affairs, com- are wheat, barley, cotton, maize, sorghum and lentils.Syria municable diseases, quarantine, statistics and malaria is poorer in minerals than in other resources, but this may be due to inadequate exploration.Salt and bitumen deposits eradication.The regional and local health adminis- are being worked.The textile industry is the most important, trations are made up of district health directorates and electric power output is being expanded. (Mohafazats) and municipal health services. Textile raw materials and manufactures, cereals and vegetable The medical faculty offers a six -year course and had products, live animal products, raw hides and skins and prepared food are exported.The principal imports are textiles, petro- 373 students in 1954 -55 and 346 in 1955 -56.The leum products, machinery of various kinds, chemicals and graduates from the medical faculty in 1954 -55 and pharmaceuticals, wood and its manufactures, vegetable products 1955 -56 were 63 and 50 respectively.In addition to and rubber products. the medical faculty a nursing school forms part of the The Syrian University at Damascus was founded in 1924. Syrian University, and another nursing school is Faculties of law and of medicine had existed previously. A Higher Teachers' College is associated with the University. attached to the Ministry of Health. Damascus is also the seat of an Arab Academy, founded in 1919. Dysentery, measles and mumps are stated to be the Lattakia is an important port.Railways connect the country most important infectious diseases.Some cases of with Lebanon, Turkey and Iraq.In 1953 there were 2584 smallpox, imported into the country towards the end kilometres of asphalt roads, 1262 kilometres of metalled roads and 6182 kilometres of subsidiary roads; a transport company of 1956, were brought under control, and a general runsacross -desertservice from Damascus to Baghdad. vaccination campaign was started.Bilharziasisis Damascus airport is served by international lines. limited to a small area where a control project is under way, and only a few cases have occurred since Health the end of 1957.A general decline has been noted The Ottoman regime in Syria lasted for four cen- in the number of patients treated for malaria -from turies.During the second half of the 19th century 131 196 in 1951 to 39 276 in 1956. A vital and health the Ottoman authorities laid down administrative statistics project is envisaged for the near future. regulations, including sanitary rules known as Tan - Progress achieved during the period under review zimat Khairieh.These rules formed the basis of the includes the establishment of health stations, clinics, public health services until 1918, when the country hospitals and sanatoria in both urban and rural areas. was given an international status.Between 1919 and Field services for the control of communicable diseases 1943 the scope of the health service was determined by such as tuberculosis, yaws and mycosis of the scalp, resolutions emanating from the Mandatory Authority. and for maternal and child health, sanitation and health Since the declaration of Syria's independence in 1943 education, have been special features of public health several public health laws have been promulgated. work during the period 1954 -56. The health services were at first supervised by a general In 1956 there were 3355 beds in government hospitals directorate attached to the Ministry of the Interior. and sanatoria, as compared with 2400 in 1952.Private hospitals provided a further 1712 beds.There were 1 On 2 February 1958 the Republics of Egypt and Syria also 12 centres and 95 dispensaries for maternal and united into the United Arab Republic. child health care. EASTERN MEDITERRANEAN REGION 343
TUNISIA
Tunisia is in North Africa, between Algeria and Tripolitania epidemiological questions; sanitary control of fron- (Libya), and extends southwards to the Sahara, with an area tiers; school health; health education of the public; of 155 830 square kilometres.There is a coastal forest area, inland from which are plains, some below sea level, intersected national campaigns; nutrition. The climateisMediterranean.The by mountain ranges. (3) population at the 1956 census was estimated at 3 783 000, and Hospitals Division :curative medicine under the annual rate of increase at approximately 2.16 per cent. government auspices;psychiatricservices;public Tunisia became a sovereign independent country in March assistance; voluntary welfare organizations; national 1956.Following legislation promulgated at different times in healthschools;medical and para- medicalarts; 1957 and 1958, the Government is now made up of twelve pharmaceutical and laboratory services. Secretaries of State and one Under -Secretary of State. The chief industry is agriculture.Of the total area of the (4)Industrial and Social Hygiene Division :super- country, about 90 000 square kilometres are productive in the following proportions: 33.9 per cent. arable; 10 per cent. forests; vision of medical services provided by industries and 9.27 per cent. orchards and vineyards; 1.1 per cent. meadow and business concerns; occupational diseases; maternal and grassland.Production in 1954 (in 1000 metric tons) was: child health. corn, 435; wheat, 189; barley, 170; oats, 6; maize, 1.7; olive oil, 53; and wine, 1 054 000 hectolitres.Other products are Medical care in the towns is provided in modern dates, almonds, oranges, lemons, pistachios, alfa grass, henna and cork, and minerals such as phosphate, iron and lead ore, hospitals, including a number of specialized units, and lignite.Fishing and sponge fishing are important on such as a psychiatric hospital, a tuberculosis hospital, the coast. a rehabilitation centre (opened in1957), a chest In 1956 all educational matters were brought under the diseases centre for children (opened in 1958), and a responsibility of the Secretariat of State for National Education, day -care centre for children (also opened in 1958). Youth and Sports, for which about 20 per cent. of the total budget is earmarked. The 210 independent Koranic schools have The country has been divided into 14 administrative been nationalized and the distinction between religious and regions as far as public health is concerned, each public schools has been abolished.Primary education is free. directed by a regional administrator, assisted by a For higher education there is a faculty of law, a centre of eco- regional public health council. nomic studies, and there is a Moslem University in the Great Mosque at Tunis. In 1958, there were 54 hospitals (including auxiliary hospitals), two hospices, and 246 dispensaries special- izing in various subjects; the total number of beds available was 8868, and there were 664 physicians and Health 40 pharmacists on the staff.During 1957, in- patient hospital days amounted to 2 461 135, and 4 058 880 Since May 1958, the Secretariat of State for Public out -patient visits were recorded.Several of these Health has been combined with the Secretariat of hospitals and medical centres have been equipped with Under this new organization, State for Social Affairs. additional facilities, such as special surgery, maternity, the following divisions are attached to the Office of ophthalmological, children's and other wards. the Secretary of State: programme and budget; Furthermore, district and suburban dispensaries personnel; hospital administration; preventive services have been set up in the larger towns, with a view to and public health; social welfare; hospitals; industrial decentralizing the out -patient services of the principal and social hygiene; and labour and workers' health hospitals and providing a solution to the problems of The new department is also responsible and welfare. overcrowding.This scheme was started in 1957, and for the outside services of the Administrative Ins- so far some 40 dispensaries have been established. pectorate and the Divisional Inspectorate of Labour. Birth, death and infant mortality rates vary con- The divisions more particularly concerned with siderably for the different ethnic groups.In 1955, matters of public health have the following functions: the birth rates were 40 for Moslem Tunisians, 31 for (1)Hospital Administration Division: organization Jewish Tunisians, and 25 for Europeans.The general of hospital services, health centres, mobile health mortality rate was 20 for Moslem Tunisians, 10 for units, etc., and legislation relating thereto; control Jewish Tunisians and 9 for Europeans.The infant and administrative and financial supervision; cons- mortality rate was 155 for Moslems, 62 for Jewish truction and equipping of hospitals. Tunisians and 37 for Europeans. The most common endemo- epidemic diseases are (2)Divisionof Preventive Services and Public malaria, exanthematous typhus, smallpox and typhoid Health: control of tuberculosis and social diseases; fever.Tuberculosis and trachoma arethe most 344 FIRST REPORT ON THE WORLD HEALTH SITUATION serious social scourges.Tuberculosis prevention at task of forming a national committee, and its activities the individual, family and school levels is carried out now extend throughout the country. by special clinics.For the control of trachoma, The second, for nutrition, was established to deal an efficient network of ophthalmological centres and with the serious problem of under -nourishment and clinics has been set up.Maternal and child health malnutrition; its programme went into operation at services are provided at hospitals, general out -patient the beginning of 1958 with the formation of a com- clinics, maternity and child welfare centres, and at mittee to undertake study and research for the im- auxiliary hospitals with out -patient departments. provement of nutrition, and with the organization of Two new sections have been established in the schemes for school feeding and supplementary feeding Office of the Secretary of State for Public Health for mothers and children. and Social Affairs, both in the Division of Preventive The Government is making every effort to improve Services and Public Health.The first,for health housing conditions, particularly by the provision of education of the public, was set up in 1956, with the low -cost housing to replace existing shacks.
YEMEN
The Kingdom of Yemen occupies the south -west corner of In 1957 an urban health unit was set up in Sana'a, Arabia, between Asir (part of Saudi Arabia) and the Aden with assistance from WHO, to demonstrate the pro- Protectorate, with an area of approximately 195 000 square kilometres.The highlands and central plateau and the higher vision of the necessary health services (other than parts of the coastal range on the Red Sea are the most fertile hospital care) for the population, and to form a part of Arabia, with an abundant and regular rainfall. nucleusforthe training of auxiliary health per- The population was estimated in 1949 at 4 500 000.The sonnel.The servicesof the unit include medical chief cities are Ta'iz, the capital, with about 8000 population; care, communicable disease control (smallpox, vene- Hodeida, the chief port, with about 30 000; and Sana'a, with about 25 000. real disease, tuberculosis, malaria and bilharziasis), The country is purely agricultural and depends wholly on sanitation, maternal and child health, and health field products.The principal export is coffee and quantities education. of hide are also exported ; barley, wheat and millet are other So far as communicable diseases are concerned, important crops. Communications within the country are very difficult and pulmonary tuberculosis is widespread throughout the many parts can be reached only on donkey or mule back. country.Malaria is stated to be one of the principal Illiteracy is a problem, especially in the villages, several of incapacitating diseases and responsible for a high which, however, have primary schools and kuttabs (Koranic percentage of sickness and death.Endemic typhus schools where elementary general education is also provided). and relapsing fever occur in the highlands and middle heights, and plague is endemic in the northern high- Health lands of Khawlan.Trachoma and ophthalmic in- A Ministry of Public Health has been established, fectionsareextremely common throughoutthe with headquarters at Sana'a, headed by a Director - country.Syphilis and gonorrhoea are also reported General.There are three hospitals - one at Sana'a to be prevalent. with about 400 beds, one at Ta'iz with about 450 beds, Among other diseases, malnutrition and nutritional and a third at Hodeida with about 400 beds.All deficiency diseases are common. The chewing of khat three hospitals are staffed by foreign doctors of various (Arabian or Abyssinian tea) has been a very common nationalities, predominantly Italian, assisted by Yeme- habit among the Yemenites, and a nutritional survey nite hakims, who have been given an apprentice- hasrecently been made which recommends the ship training by the foreign doctors.Since 1954, seven prohibition of the cultivation, importation and use of Yemenite students have been taking a full medical the plant, owing to its ill effects on the health of the course in Egypt, and it is expected that fully -qualified population. medical graduates of Yemen nationalitywill be A systematic smallpox vaccination programme has available to serve their country from the beginning been carried out by the urban health centre at Sana'a, of 1959.Ten students are studying sanitation at the and as a result of successful demonstration of this Hygiene Institute in Cairo, and one student is following work the Government has recently passed a law a course in vital statistics at Cairo University. making smallpox vaccination compulsory. WESTERN PACIFIC REGION FIG. 11.WESTERN PACIFIC REGION
. . ".^:Hklla` n. ':::NEW GUINEA AMERICAN SAMOA
American, or Eastern, Samoa, has the general characteristics The birth rate was reported to be about 40 in 1957, of the Samoan group.The area is about 197 square kilometres, and the death rate about 10.There is considerable and the population at the 1956 census was 20154, almost entirely indigenous. emigration; 60 per cent. of the people are under For local administration, the territory is made up of three 20 years of age, very few being over the age of 50. districts, each divided into counties and further subdivided into The chief causes of death are pneumonia, heart villages.Each district is headed by a Samoan governor, who disease and a number of chronic conditions in the is appointed by the Governor of American Samoa from the ranks of county chiefs.The district governor presides over the oldergroups, and malnutrition, prematurity, and district council.The county chiefs, who are hereditary, preside gastro -intestinalconditionsin infants and young over the county councils.The village council is headed by a children. chief, selected from the matais, subject to the approval of the The Governmentoperatesa151 -bedgeneral district governor.The matai, who is head of his immediate hospital, a 56 -bed tuberculosis hospital, a 30 -bed clan, plays an important part in local affairs. The economy is essentially agrarian, and the principal exports leprosarium and four dispensaries. arefishproducts,copra, and handicrafts.The principal At the end of 1957, the Samoan medical staff imports are food and textiles. numbered14. The Department alsohad three The educational policy of the Government is to provide registered nurses, 73 Samoan certified nurses, and training suited to conditions in the territory, to provide at the same time a suitable background for those who will proceed to 56 nurses intraining.One dental surgeon and higher education in the United States of America or elsewhere, fiveSamoan dentalpractitionersconstitutedthe and to lead the people towards self -government.The means dentalstaff.There is no medical school in the proposed include compulsory education in Samoan and English territory, and dental staff are trained at the Central from 7 to 15 years of age, and scholarships. Medical School in Suva, Fiji.Five medical students, In 1957 there were 43 public and six private primary schools, six public secondary schools, one public vocational school and three dental students and one pharmacy student one public teacher -training school.Pupils attending the primary were in training in 1957.Nurses are trained in a schools numbered 5975, secondary schools 256, the vocational four -year course at the Samoan hospital. school 70, and the teacher -training school 14. No malaria and very few cases of trachoma are reported, the major problem being filariasis.Rheu- Health matic heart disease and acute yellow atrophy of the The Department of Medical Services has two liver seem to be unusually prevalent.An island - main divisions -public health and hospitals.Out- wide programme of inoculation against typhoid and lying dispensaries and village health activities are paratyphoid diseases was initiated in 1955. dealt with by the public health section, which is Water - supply systems or reservoirs and distribu- also active in sanitation (including garbage disposal) tion pipelines have been, or are being, developed and insect and rodent control. for many of the villages. A programme for the Approximately 25 per cent. of the government development of additional ground- and surface -water budgetisdevoted to medical services,of which suppliesis under way.The inspection of eating 8 per cent. goes to the public health services and establishments and water and sewage -disposal systems the remainder to administration and medical care. has been intensified.
AUSTRALIA
Australia may be called the largest island in the world or the farming.Further inland the districts are well suited to sheep smallest continent.It extends from 10° to 39° south and from farming.The climate is mostly very dry but more humid areas 113° west to 153° east.Its greatest dimensions are 3840 kilo- extend for considerable distances near the coasts.The northern metres from east to west and 3152 kilometres from north to portion is subtropical to tropical, with sharply differentiated south.The area is 7 614 912 square kilometres.An eastern " wet " and " dry " seasons subject to monsoonal influences. and a western area may be sharply distinguished.The eastern The population, which was 8 986 530 according to the 1954 has a regular coastline with good harbours, rivers and inland census and 9 427 558 according to that of 1956, is 98 per cent. waterways.Much of the interior, especially towards the west, of British descent.There is a consistent policy of regulating is sandy or stony desert with many salt marshes and some alien immigration. reaches of grassland.Most of the land around the coast, The Australian system of government is a federation of as well as that driving far inland in the south and south -east, states, having a Federal or Commonwealth Government with isfertile, devoted partly to agriculture and partly to dairy certain delegated powers under a Federal Constitution, and six - 347 - 348 FIRST REPORT ON THE WORLD HEALTH SITUATION state governments each with its own state parliament and tories, and the Commonwealth Health Laboratories administration responsible for public services of many kinds throughout Australia.The Medical Administration not administered by the Federal Government. The Commonwealth Government isresponsible for the Division controls the Northern Territory Medical Ser- administration of foreign affairs, trade, defence, immigration, vice, the Australian Capital Territory Health Services, a national health and social services scheme, as well as a number and nutrition research. of other fields of administration, including all postal services. The Commonwealth Health Department has offices Among the main functions of state governments are educa- tion, public health (including hospitals) and railway transport in each state and is also represented overseas. services.There isa system of local government through Each state has its own Minister for Health, who municipalities, boroughs, shires,cities, towns and districts, controls a state health department.The latter has which administers certain areas of public health, including direct responsibility for public health, food and drug water supplies and sewerage, roads, recreation facilities, etc. control, disease control and hospital administration. A number of other services, including some health services, function at federal and state levels under specially created The SocialServices Act,administered by the Boards and Commissions.Examples of these are State Hospital Commonwealth Government, provides for the pay- Boards, State Electricity Commissions, State Parks Boards ment of invalid, old -age and widows' pensions subject and Main Roads Boards at the state level, the Australian to a means test on income and property and residence Broadcasting Commission atthe federallevel,and joint authority such as the Snowy Mountain Authority. tests.Unemployment andsicknessbenefitsare Australia is one of the principal primary producing countries payablesubjecttoan incometestonly.Other of the world, though there has been considerable industrial benefits payable under the Act are maternity allow- development in recent years.Its most valuable export is wool, ances and child endowment; these are not subject followed by food exports - meat, wheat, flour, fruit, sugar and to a means test.Service pensions are paid under butter.Chief imports are manufactured goods, particularly machinery and motor vehicles, and consumer goods such as the Repatriation Act to returned servicemen who are motor spirit and oil, cotton, linen, rayon and silk piece -goods, over sixty years of age and who are permanently tobacco and tea.Production is substantially in the hands of unemployable or who are suffering from tuberculosis; private enterprise. these pensions are subject to the same means test as The great distances in Australia have encouraged aviation, which is subject to Commonwealth control and connects the is applicable under the Social Services Act.War seven capital cities and Darwin in the Northern Territory. pensions under the Repatriation Act are payable The Royal Flying Doctor Service, which is subsidized by both in respect of a war disability.The social services commonwealth and state governments, has made a great mentioned above are of many years' standing, some contribution to medical care in remote areas, as has also the dating back to 1908. Northern Territory Aerial Medical Service, which is run by the Commonwealth Department of Health. Hospitalandmedicalbenefitssupplementing voluntary insurance, and pharmaceutical benefits are Health now paid under the National Health Act of 1953. However, hospital benefits have been paid since 1945 The health services in Australia may be divided and pharmaceutical benefits since 1947.These were into two broad groups: commonwealth and state. originally provided under legislation which has been The Commonwealth Health Services are controlled superseded by the National Health Act.Allowances by the Federal Government in Canberra, and their to infectious sufferers from tuberculosis have been organization provides for a Minister of State for paid since July 1950, under the Tuberculosis Act Health, who is in control of a Department of Health of 1948. headed by a Director -General.This Department has The main health problems are those of homogeneous divisions for the administration of its many functions communities, the only special problems being recurrent -the National Health Division (dealing with the malaria and endemic leprosy in the tropical north, administration of the National Health Act), the Public where communications are difficult and where there is Health, General Administration and Medical Admi- a large indigenous component in the population. nistration Divisions.The Public Health Division is Notifiable diseases are reported to the state health subdivided into sections on tropical hygiene, health departments from all city and country areas.Returns laboratories, acoustic laboratories and dental standards are prepared on a weekly basis and forwarded to the laboratories, national fitness, immigration and human Commonwealth Department of Health where they are quarantine, plant quarantine, and veterinary qua- consolidated for distribution to interested authorities, rantine. including WHO. The General Administrative Division includes in its Through the state registrars of births, deaths and control such activities as the Commonwealth X -ray and marriages, statistical information is received by com- Radium Laboratory, the School of Public Health and monwealth and state government statisticians; the Tropical Medicine, the Commonwealth Serum Labora- reporting provides a complete coverage of the popula- WESTERN PACIFIC REGION 349 tion and allows for the preparation of full vital sta- out campaigns against diphtheria, whooping -cough tistics. and, more recently, poliomyelitis. A Health Week is In 1955 the birth rate was 22.5, the general mortality conducted each year for publicity purposes. rate was 9.13, and the infant mortality rate was Maternal and child health services in Australia are 22.23. of a high standard, the infant mortality rates being There are approximately 10 100 doctors in hospital among the lowest in the world.In 1955 the rate for or private practice in Australia.The majority of the whole country was 22.01, while in onestate these are in New South Wales and Victoria, the two (Victoria) the rate was 18.37.The services are for states with the highest population.Of the 4194 den- the most part controlled by special maternal and tists registered in Australia, 3235 have private practices infant welfare divisions of the state health depart- and 414 are in full -time government or institutional ments.These divisions work in close co- operation service; 545 are not practising. with local government and voluntary agencies.For In the Australian Capital Territory and the Northern example, in New South Wales, the specially designed Territory, the Commonwealth Department of Health buildings for infant welfare centres are provided by provides a full dental service for schoolchildren, while local government authorities, while staff is appointed in the states a fairly complete dental service for school- and controlled by the state health department.Some children is also provided by the state authorities.The hundreds of infant welfare centres have been established treatment of adults is mainly in the hands of private in all states, Victoria alone having 543 centres in practitioners, the indigent being treated in dental hos- operation.Special training courses are provided by pitals and general hospitals. the maternal and infant welfare divisions,or in In 1956 the total number of hospitals in Australia special training schools; refresher courses are also was 1621, providing 70 675 beds.For tuberculosis provided, and in some states there are pre -school patients there were, in the same year, 4681 beds avail- training courses for mothercraft nurses, play- leader able.In mental hospitals, the average number of training courses and child care courses for nursing patients in residence in 1955 was 29 323. bursary holders. Most of the general hospitals provide some beds Occupational health services in private industries are for the chronic sick.The proportion varies with not organized on a routine basis, and it can be said different hospitals, and depends a good deal on the that such services are few with reference to the total amount of accommodation available in private institu- number (approximately 50 000) of private factories tions.The total number of beds for the chronic sick in the country.Even some large industries with must run into several thousands but the actual numbers serious potential hazards have no arrangements for have not been ascertained.Most of the aged prefer regular visits by a physician.No specific requirement to live in their own homes, or with friends or relatives. for private industries to provide occupational health In more recent years, a number of the churches and services is laid down by law, although in some states voluntary agencies have established homes for the regulations require factories of a certainsizeto aged and chronic sick, with financial assistance, re- employ a nurse, or certain industries -such as lead presenting two- thirds of the cost, in the form of a processes, or where there is exposure to benzine - building subsidy from the Commonwealth.Under to provide medical examinations.In New South the National Health Scheme, all persons entitled to Wales approximately 100 private establishments have old -age, invalid, widows' and service pensions, and arranged for regular visits from a medical officer. their dependants, are provided with free medical Under the Commonwealth Health Department a treatment of a general practitioner nature in their own unit of industrial hygiene and medicine was esta- homes or at a doctor's office.It is customary for the blished in1949.The functions of the unitare state governments to provide homes for the aged in teaching, research, investigational, consultative and which there is a hospital section.In such cases the advisory.Allstatedepartmentsofhealthare necessary hospital care is provided there and not in engaged in industrial hygiene work and in New South general hospitals.District nursing services are oper- Wales, Victoria and Queensland full -time divisions ated to provide health care of the aged within their have been established within the departments.The own homes. functions are mainly advisory and consultative but Health education of the public is primarily a function some states have statutory powers in this field. of the state governments.It is carried on through the Environmental sanitation is the function of state state education departments in relation to schools, and local government administration, the Common- and all state health departments undertake some wealth having jurisdiction only in the Australian measure of health education activity and have carried Capital Territory and the Northern Territory.By far 350 FIRST REPORT ON THE WORLD HEALTH SITUATION the greater part of the population is served by com- There are 14 Commonwealth health laboratories, munity water supplies of various kinds.The recent which give service in the fields of pathology, bac- rapid growth in population and the hasty development teriology and biochemistry. These laboratoriesare of new housing projects have reduced the proportion additional to those which serve the various large of population served by a water -carriage sewage hospitals and the state government laboratories. disposal system to a figure below 40 per cent. Each state government has its own legislation for Except in special areas the control of water pollu- the control of food and drugs, administered by the tion is undertaken by local authority.There are state health department.The National Health and some special water boards and irrigation commissions Medical Research Council has set up expert sub- invested with powers under legislation in respect of committeestodeal with standardization and to the conservation and protection of water supplies. encourage uniformity in state legislation.
BRITISH SOLOMON ISLANDS PROTECTORATE
The Solomon Islands lie between 5° and 13° south and the houses are, with a few exceptions, built of local timber and between 155° and 170° east.The population, estimated at leaf. 100 000 in 1954, consist of 94 000 Melanesians, 4350 Polynesians, and a number of smaller groups, including 600 Europeans. Nearly half the Melanesians live on the island of Malaita, while Health the Polynesians inhabit outlying atolls and small islands.The larger islands are mountainous and forest -clad and the total land A medical officer was first appointed to the territory area is nearly 30 000 square kilometres.Most of the population in the early1900's,and the Medical Service developed inhabit areas within easy reach of the sea -coastal areas of the steadily until the outbreak of the Second World larger islands, islets (some of them artificial) in the lagoons, and War.Immediately after the war the entire Medical some outlying islands.Villages are small, the largest having about 400 inhabitants, and many family groups live in isolated Service was reorganized and reconstituted and has conditions.The people still follow the customs and traditions been considerably extended. of the close family group, and this group is responsible for the The organization of the Medical Department is care of the old, infirm and disabled. centralized, and health projects are carried out by The economy of the territory depends almost wholly on the production of copra, and restoration of this industry has been district medical officers with the help of assistant one of the main tasks of the Government since the end of the medical officers and dressers.The missions take an war.Agricultural policy was reviewed in 1954 with the object active part in the hospital service, and undertake a of improving the management of coco -nut plantations and the great deal of general medical work.The Central storage of copra; the establishment of cocoa as a cash crop; a Hospital in Honiara has 132 beds, and includes a rice research scheme; and an endeavour to restock the plantations with cattle. maternity department and a33 -bedtuberculosis Education is not compulsory, but free education is widely section.There are three district hospitals (with a total available.The missionary societies, which formerly provided of 127 beds), of which two are being completely rebuilt. the only educational facilities, continue to provide pre -primary A leprosy hospital at Tetere, some50kilometres and primary schools, many of which receive government from Honiara, accommodates 100 patients and is subsidies.Local government councils assist in the provision of equipment and encourage the establishment of schools by com- visited weekly by a medical officer.Two mission munal effort.The central Government has set up seven primary hospitals, one in the west and one on Malaita, are schools, operates the King George VI Secondary School at subsidized by the Government and have a total of Auki on Malaita, and has built a training centre for teachers and 130 beds; each has a resident doctor.There are craftsmen at Honiara.The Education Department administers the government subsidies to schools and supervises schools also 63 rural dispensaries. operated by the Government.There are two private fee- paying The curative services offered in district hospitals schools in Honiara, run by the Chinese community and a mission and rural dispensaries have been supplemented by body respectively.Normal age ranges are from 9 to 14 in the preventive measures against communicable diseases. primary schools and from 13 to 19 in the post -primary schools. Yaws has been a great problem, but a campaign Instruction in the first is usually in the vernacular, but the use of English is increasing rapidly, while in the second it is invariably against this disease, which was carried out in1958with in English.In 1950, five per cent. of the population were assistance from WHO, has reduced it considerably. estimated to be reasonably literate in English, and 20 per cent. Tuberculosis is prevalent and, with malaria, cons- to be enrolled in schools. titutesthe principal threat to the health of the Honiara, the capital, which now has a population of over 2000, is administered by a Town Council.In Honiara most of people, although there isalso widespread helmin- the buildingsare of permanent materials- concrete,fibro thiasis- especiallyhookworm -and anestimated cement, timber and corrugated iron or aluminium.Elsewhere 1500cases of leprosy.Active planning is now under WESTERN PACIFIC REGION 351 way with a view to introducing antimalaria and of health education when the hours of broadcasting antituberculosis campaigns in the territory. are increased. Dental services are provided by a private dentist Increasing numbers of local personnel are sent to from New Guinea twice a year, and also by assistant Fiji for training as assistant medical officers, dental medical officers trained in the Central Medical School officers and auxiliaries.The only qualified nurses in in Suva, Fiji.There are no private doctors or dentists the territory are at headquarters and at the mission in the territory.Maternal and child health services hospitals, but a training school has been established are conducted in conjunction with the Central Hos- in Honiara, where 30 Solomon Island girls are at pital, and similar services are available at the district present under training.Medical assistants receive and mission hospitals. instruction in environmental sanitation and carry Health talks over Honiara radio are given from out a certain amount of health education work time to time, and it is hoped to develop this aspect during their training.
BRUNEI
The territory of Brunei lies north of the equator, on the north- the territory.In an oilfield in the southern end of west coast of the island of Borneo in the South China Sea.It Brunei, the petroleum company concerned provides consists of two separate territories bounded on land by Sarawak. The country is mountainous and is interspersed with several all these services for its employees and their depen- river valleys.Large sections are covered by dense forests.The dants. There is close liaison between the government climate is tropical, and is characterized by uniform temperature, and company medical services. high humidity and copious rainfall.The heat is usually tempered Expenditure on the Medical and Health Department by a slight breeze and the temperature rarely exceeds 32° C; the usual daily range is between 23° and 30° C. in 1957 amounted to Str. $2 195 976 (US $724 745), or The area is 5765 square kilometres, and the estimated popula- about 5.9 per cent. of the total budget of the territory tion in 1957 was 75 046.The principal indigenous groups are for the year. Malays, Kedayans, Dusuns, Bisaya and Muruts; of the immi- The birth rate for 1957 was 45.23, the death rate grant races, Chinese are the most numerous, with an estimated was 15.09, and the infant mortality rate was 127.11. population of over 14 000. A number of Europeans are con- centrated in the Seria and Kuala Belait areas, and 329 were Great attention has been paid to the collection of employed in the oilfields in 1957.There are also small numbers statistics, and it is thought that these figures may be of Indians and Arabs. within 10 per cent. either way of accuracy. The territory is divided into four administrative districts, in A general hospital with 150 beds is maintained in each of which there is a Malay District Officer responsible to the Resident.In Brunei Town, Tutong and Kuala Belait there are Brunei Town in the north, while in Kuala Belait sanitary boards responsible for general environmental sanitation in the south there is a district hospital with 75 beds. whose members are appointed by the Government. The petroleum company mentioned above also main- The Malays are fishermen, cultivators of wet paddy, rubber tains a general hospital with 140 beds in Kuala Belait. and fruit plantations, and they also have small domestic indus- There are two rural dispensaries with ward accomoda- tries such as silverwork, carpentry and basket -making.The Dusuns and Dyaks are mostly land cultivators. tion, four river and two road travelling- dispensaries, The main export industry, which has raised the standard of six major maternal and child welfare centres, and living, is the production of oil.The principal imports are rice, numerous subsidiary centres.There are three main petroleum products and machinery. dental clinics, and dental care is given to school- The development programme 1953 -58 provides for expendi- ture of Str. $100 000 000 (US $33 003 300) over and above children by two dental surgeons, who travel by road annually recurrent costs of public works.Actual expenditure and river. A school dental service based on the on the development programme and public works together New Zealand model has been started. amountedtoStr. $21.8million (US $7 194 719)in1955, A vigorous campaign against tuberculosis has been Str. $21.8 million in 1956, and Str. $26 million (US $8 580 858) put into operation, using mass miniature radiography, in 1957.Expenditure on the development programme alone has so far amounted to nearly Str. $60 000 000 (US $19 801 980) tuberculin- testing, and contact survey, together with between 1953 and 1957. hospital and out -patient treatment of confirmed cases. This work is greatly facilitated by a scheme of monetary Health allowances paid by the Government to those patients The State Medical and Health Department provides and their dependants who are in proved need of hospital, rural dispensary, maternal and child health, financial help. environmental sanitation, tuberculosis, dental, anti- By means of an annual programme of DDT residual malarial, municipal and port health services throughout spraying of dwellings in the rural areas, together 352 FIRST REPORT ON THE WORLD HEALTH SITUATION with drug therapy, malaria has been reduced to taken at the nurses' training school at the State insignificant proportions.Filariasisis endemic, as Hospital. Dental nurses, laboratory, x -ray and dental are the helminthic diseases.Anaemia and protein technicians, and health inspectors are sent to the and vitamin A deficiency are widespread in the Federation of Malaya for training. territory. Treated piped water is supplied in the three major A school feeding scheme, which is entirely free, towns, and small supplies are being conveyed to is run by the Education Department and provides villages.No majorwater -bornesewage- disposal either a daily meal or a daily fortified drink to 11 260 scheme has yet been started, although complete plans schoolchildren each school day. for such schemes in Brunei Town and Kuala Belait The training of nurses, hospital assistants, assistant are now ready.Sanitation at the present time is of nurses, assistant health nurses and midwives is under- the septic tank type or bucket system.
CAMBODIA
Cambodia occupies the south -west part of Indo- China, and Medical care is provided in 22 hospitals (seven in the is bordered by Thailand, Laos, Viet Nam and the Gulf of Siam; capital and 15 in the provinces), with a total of it has an area of about 175 000 square kilometres.The country is mountainous in the west and there is a central depression 3500beds.Among theseestablishmentsarean -the Mekong Valley- where, in the rainy season, the Great Institute of Ophthalmology, a leprosy settlement with Lake is formed by overflow from the Mekong River.The 600 beds, and special units for venereal diseases, climate is monsoon and tropical. communicable diseases and tuberculosis.In addition, According to the latest census, the population is estimated at 5 010 000, with a density of 28 per square kilometre.The there are 26 dispensaries in the capital and 119 in the capital, Phnom -Penh, has a population of 375 000.The Cam- provinces.All the hospital staff are employed on a bodians, who make up the majority of the population, are of full -time basis. Khmer race, but there are also minority groups which include Cambodia has a psychiatric hospital, which is well Vietnamese, 250 000 Chinese, and Laotians in the border region known as a treatment centre where modern methods of Stung Treng.There are also some 3000 people of European origin. are used, and which deals with both mental diseases The population is unevenly distributed: it is very sparse in the and drug addiction. wooded regions, fairly dense in the plains, and extremely con- A medical school, which is under the patronage of centrated in the Mekong Valley, where the land is fertile and the Faculty of Medicine in Paris, has been established fishing is abundant. Cambodia is an agricultural country, and the predominant for the training of doctors and health officers.Special occupation of the people is farming, but there are also artisans. training courses for nurses and midwives have been There are no important metallurgical or chemical industries. organized for the existing staff, and a school of nursing The principal resources are rice, fish, cereals, game, rubber is being set up in Phnom -Penh. and wood. The scope of dental care is somewhat limited; there The country has 1653 primary, elementary and post -primary schools, 1500 modernized pagoda schools (where general educa- are seven dental clinics in the capital of which two are tion is now given as well as religious instruction), 20 secondary public and five are private; in the provinces most schools and 24 provincial technical schools, with a total of of the dental care is undertaken at the hospitals. 375 719 pupils. At the present time the Government is giving serious In the capital there are also a teachers' training college, a pro- fessional training institute, faculties of law and medicine, and attention to the problems of chronic disease and the training schools for forestry inspectors, leaders in public works care of the aged sick.No definite plans have yet and other technical subjects, such as forestry, agriculture and been put forward for an industrial health programme, cadastral survey. and there are no special centres for rehabilitation. However,existinglegislationprescribesthat any Health enterprise employing more than 50 persons must The health services are directed by a Minister, provide a nursing station for medical care of the assisted by a Director of Health Services, who is a workers.The rubber plantations have their own physician.There are 15 medical divisions, corres- medical service, which possesses small hospitals and ponding to the 15 provinces, each directed by a chief employs foreign doctors. medical officer under the administrative authority Regulations in force require all doctors and mid- of the Governor of the province, as the representative wives, as well as administrative authorities, to notify of the Minister of Public Health at the provincial level. the provincial authority of every known or suspected WESTERN PACIFIC REGION 353 case of infectious disease, such as typhus, cholera, the school population; improvement of the school plague and smallpox.The necessary isolation and dispensaries; and the establishment of a domestic disinfection measures are then taken.There are science demonstration and training centre. special wards for epidemic diseases in the various By the application of health education methods, hospitals. the rural population has been given an understanding There is a Pasteur Institute at Phnom -Penh. of the basic principles of hygiene and has been helped In general, the results of the malaria control cam- to build wells, latrines, and pit -privies. paign have been encouraging so far, and there is close Considerable efforts are being made to improve co- operation with the neighbouring countries of Laos, environmental sanitation. At the present time approxi- Viet Nam, Thailand, Burma and the Federation of mately one -half of the population of Phnom -Penh Malaya, with the object of eradicating this disease. and the provincial capitals are provided with safe As a first step in the control of tuberculosis, a drinking- water; the remainder of the urban population BCG vaccination campaign has covered almost the and the entire rural population depend on rain -water, entire population. wells or rivers, for their water supply. Until now, maternal and child health services have In Phnom -Penh, a municipal healthserviceis been limited to the capital, but they are to be extended responsible for sanitation and for preventive measures gradually totheprovinces. A specialchildren's such as vaccination.The scope of this service is still hospital is to be established in the near future. verylimited,owing tothelackof funds and Noteworthy progress in the school health pro- qualified staff. gramme has included: medical inspection of the With a view to the improvement of rural hygiene, various schools in Phnom -Penh; courses in hygiene, a health centre, destined to serve as a rural health child care and nutrition for student -teachers and demonstration area, is being set up in a district very physical education instructors; distribution of milk to close to the capital.
REPUBLIC OF CHINA
Taiwan, the seat of the Republic of China, known also In the county and city governments, the health as the island of Formosa, lies between 21° and 25° north authority is termed the" health centre "andis and 119° and 112° east.The island is about 630 kilometres long and 135 kilometres wide and has an area of 35 961 square equivalent to the county or city department of health. kilometres.It is highly populated, the latest estimated figure Under these centres are the health stations, one in being nearly 9.5 million. each township or village. A health centre therefore Taiwan Province is divided into 16 counties, five cities and directs the work of as many health stations as there are one special administrative area. A magistrate or mayor, elected by the people, heads each of these districts, which are further townships, villages or city districts within its area; divided into townships or villages, totalling 368 in number. it carries out in detail the curative and preventive medical servicesallotted by the provincial health Health administration, and further directs the work of the The Taiwan Provincial Health Administration is health stations, which intheir turn are actually generally responsible for the public health services in responsible for providing the clinical and preventive the Province, including both curative and preventive medical service in the local community.The remoter medicine, the training of health personnel and quaran- health stations are in fact small clinics controlled by tine.Itdischargesitsduties through two main the health centres. A very small fee is charged for channels.One (adirect channel)isthrough the treatment of the sick and free service is provided for 12 provincial hospitals, 13 quarantine stations, the the poor.Mornings are spent in clinical work and Malaria Research Institute, the Serum and Vaccine afternoons in health work such as maternal and child Laboratory, and the Institute of Laboratories, and welfare. A health station of this kind usually serves oneProvincial Health Demonstration Area and a population of up to 30 000. Centre.These institutions are under the provincial The health personnel of Taiwan consists of just over budget and under the direct control of the Commis- 4000 doctors, 1700 herb doctors and 700 dentists. sioner of Health of the Provincial Health Administra- There are over 1800 midwives, 700 nurses and a tion.The second channel, which is indirect, is through considerable number of auxiliaries, such as pharma- the health centres and health stations. cists and nursing aides. 354 FIRST REPORT ON THE WORLD HEALTH SITUATION
The main work of health education is carried out in carried out by untrained helpers.Every effort is being the elementary schools.In Taiwan there were 1118 made, through the health stations, to introduce courses such schools in 1955, with about1 200 000 pupils. of training and short refresher courses for midwives Health knowledge is imparted through the routine in the provinces. educational courses, and the schools hold various Child health care is undertaken at the health stations, active health education programmes sponsored jointly where various kinds of immunization are practised. by the provincial educational and health administra- Practically all children between the ages of 6 and 12 are tions.The principal methods consist of holding reported to have been vaccinated with BCG. The meetings at which films and exhibitions are shown. provincial government and the health and education Services are mainly undertaken by voluntary health departments sponsor the school programme.There agencies. is a school health committee, with its supervisors, for The statistical section is a function of the provincial all the schools.All schoolchildren and the staffs are health administration.Estimates show that the birth tuberculin tested and negative reactors are given rate reaches the high figure of 44, and the crude BCG vaccination. death rate is about 8.The infant mortality rate is Within the period 1955 -56, over a million school- not accurately known, the estimate given being 34. children were examined for trachoma, and it was In the hospital service, including the small branch revealed that more than half of them were affected, hospitals, there are in all 21 institutions with a total while an additional 10 per cent. had conjunctivitis. of 2860 beds, and 64 private hospitals with 966 beds. All positive cases were treated, and the system The principal institutionisthe National Taiwan was extended to family contacts. University Hospital.Medical care units are attached A committee for the inspection of industries was to various industries and other organizations, providing established in 1951 by the central Government.Pro- a further 966 beds. vincial departments of reconstruction and social wel- The provincial government lays great emphasis on fare carry out the detailed work, including the health the in- service training of all categories of health inspection of industries.Environmental sanitation workers.They are called to demonstration centres conditions are regularly inspected.Training courses for refresher courses and some are sent abroad for are held to teach the personnel basic health knowledge, advanced training.Public health training in the such as the prevention of occupational diseases.In Institute of Public Health began in 1954; courses of the mining areas there is a hookworm control pro- two months are offered, and outside lecturers in gramme, and the local health authorities undertake various fields take part in the work.Trainees are the physical examination of workers and the treat- chiefly medical officers of the health centres and sta- ment of industrial defects. tions, with a small number of sanitary engineers, A mental health programme is being developed sanitarians and nurses.Up to the present nearly in co- operation with the Department of Neurology 500 staff have been trained at the Institute. and Psychiatry at the National University Hospital. In Taiwan there are three medical colleges.The The Division of Mental Health has organized pro- National Taiwan University College of Medicine has grammes for instructing school- teachers, public health a seven -year programme, while the other two follow nursesand nursingstudentsinmentalhealth. the six-year system.The colleges are under the super- Demonstration classes have been set up for this pur- vision of the Ministry of Education.The final year of pose, and mental health booklets have been issued. the medical course is spent in a rotating internship at In 1955 a Chinese Mental Health Association was the teaching hospital or one of the affiliated units. established, the members consisting of psychiatrists, The provincial health administration selected Tainan psychologists,socialworkersandpublichealth city and Chia -yi county as demonstration areas for the staff.A mental health bulletin is now being published prevention of dental caries, using fluorine forthis quarterly. A children's mental health centre has purpose.Some 12 000 children were kept under been set up, and plans are in progress for building observation, and the oral application of fluoride is a governmental institute. being studied.Similar demonstration schemes have Anopheles minimus, the chief vector of malaria in been organized in other areas. Taiwan,isbeing effectively controlled by DDT - Ante -natal examinations are held at the health spraying of houses.Between 1952 and 1956 the centres and health stations.Delivery is usually under- homes of 7.5 million of the population were sprayed, taken by private midwives except in the town health and the number of clinical cases dropped from well centres, and most confinements take place at home. over a million in 1946 to 377 in 1956.There has About 40 per cent. of the deliveries in rural areas are been no outbreak of cholera or plague since 1946 and WESTERN PACIFIC REGION 355
smallpox has not been seen for years.Typhoid and a complete sewage -disposal system has been planned. paratyphoid fevers, together with dysentery, still cause A national committee of housing has been established, a small number of deaths.Rabies is still prevalent and between 1953 and 1956 large sums of money were and active measures are being taken for its prevention. lent for housing construction and nearly 4000 houses With regard to environmental sanitation, water were built. supplies have improved considerably in recent years. A number of voluntary organizations are connected Supply areas have now been set up in 180 places and with the government health services, notably the cover a population of nearly 2.5 million, 26 per cent. Red Cross Society, the Taiwan Tuberculosis Associa- of the total population of Taiwan province. Chlorina- tion and several other bodies.Those which function tion of water has been carried out in the larger water- at the provincial level are all under the supervision works, and bleaching powder is used in the small of the Social Welfare Administration.There is a units.There are four water examination centres in considerable number of voluntary organizations in the province.Sewerage and sewage disposal had which the people themselves take part, including some hardly been developed hitherto, but in 1956 small especially for boys and girls.The aim of all these septic tank systems were constructed.In Taipeh City organizations is to train local leaders in health work.
COOK ISLANDS
The Cook Islands consist of 15 small and widely scattered is also sanatorium accommodation for 64. A few units, spread over an ocean area of nearly 1.5 million square more small hospitals exist, but the majority of the kilometres.The group extends from 8° to almost 23° south, and from 156° to 167° west.The total land area is about islands are served by dispensaries, linked by radio 229 square kilometres. with the larger units. The census taken in 1956 showed a total population of 16 424, For the year ended March 1958, the total number of the largest concentration being in Rarotonga, the population deaths was 238, with broncho -pneumonia as the of which (7212) is increasing steadily, partly at the expense highest individual cause.The infant death rate (1955) of the other islands. was estimated to be 150.In Rarotonga, prematurity and gastro- enteritis are cited as the chief causes, foll- Health owed by measles and malnutrition.The islands are There are no private medical practitioners or dentists relatively free from the true tropical diseases, but in the territory.The medical officers in government filariasis, yaws, intestinal helminths, and leprosy are service hold a New Zealand degree or its equivalent. prevalent. The Cook Islands medical staff are trained in Fiji and In the northern group of islands the inhabitants return there for post -graduate study.The nurses in have in the past had a simple, adequate diet consisting training are given a three years' course in Rarotonga mainly of fish and coco -nut products; but on some hospital, and, in selected cases, higher training in islands, the money earned from pearl shells has been Suva.Dental students, dressers, and sanitary inspec- used for the purchase of store foods, with the result tors are given local training, and some go on to the that dental and general health have suffered.In the full course in Fiji.The medical staff numbers 120, southern group the diet has been chiefly composed of of whom the chief medical officer, the assistant, the carbohydrates, with some fish and canned meat. matron, and three sisters are from overseas.There In Rarotonga, scarcity of sea foods results in increased are 15 Cook Islands medical practitioners, six ap- use of imported foods. pointed health inspectors, 21 trained Cook Islands Generally speaking, the average income isnot nurses and 30 trainees, and eight technicians. enough to provide good housing for the usually large On Rarotonga there is a general hospital with a families, and overcrowding is rife.The New Zealand capacity of 57 beds, including a six -bed maternity Government has recently approved an assisted housing unit, a dispensary, and limited x -ray facilities.There scheme. 356 FIRST REPORT ON THE WORLD HEALTH SITUATION
FIJI
The territoryof Fijicomprises about 300 islands(of the territory is divided into four medical districts, which a hundred or so are inhabited) with a total land area of each in the charge of a district medical officer.He has 18 230 square kilometres. Itliesinthe South Pacific, about 2800 kilometres north -east of Sydney, Australia.The a staff of nursing sisters, health inspectors, locally larger islands are mountainous and volcanic.The climate is trained assistant medical practitioners, assistant health tropical, with marked variation in rainfall between the areas of inspectors and nurses.The medical staff is stationed the larger units which are exposed to the prevailing south -east at hospitals, dispensaries and health offices throughout trade winds and those which are sheltered from the trades by the territory. great land masses.There is a well- defined rainy season from December to March, and the annual rainfall varies from a Health expenditure represents about 12.5 per cent. maximum of 290 centimetres on the exposed side to a maximum of the total budget.Vital statistics for the period of 140 centimetres on the sheltered side.The exposed coastline under review were as follows : consists usually of open sandy beaches with flat alluvial soil 1954 1955 1956 bearing many coco -nut palms, whereas the sheltered parts and Fijians Indians the mouths of the larger rivers are screened by wide areas of Birth rate 40.2 38.5 35.59 44.47 mangrove swamp.Where rainfall is heavy, the hills are covered Death rate 8.2 7.24 7.52 7.19 in dense forests but the drier areas have been cleared. Infant mortality rate 55.87 46.11 48.16 44.54 The population is estimated at 358 000, of whom 26 000 live in the capital, Suva. The Fijian, East Indian and European The statisticalsectionatheadquarters,inthe communities represent three separate cultures.The structure of the population is changing fundamentally because the Indian charge of a senior medical officer, keeps routine group is increasing more rapidly than the Fijian.Women, as follow -up records of tuberculosis and leprosy patients members of many government boards and committees, play an and compiles epidemiological returns for outside important part in public life. organizations. The Fijian social organization is arranged on a highly de- veloped communal basis, and the unit is always larger than the The main government general hospitals are the family.The villages consist of anything from three to fifty Colonial War Memorial Hospital at Suva (275 beds) houses in which live a group of blood relatives, usually of three and three district hospitals with a total capacity of generations; but these dwellings are not regarded as the exclusive 551 beds.There are in addition 14 rural government reserve of one family, and there is free visiting and sharing of hospitals, and three private and mission hospitals clothes, utensils and tools. The economy of Fiji depends mainly on its agriculture, and the subsidized by the Government with a total of 57 beds. chief crops are sugar -cane, coco -nuts, rice and bananas. The more specializedunitsarethe Government Education is compulsory on the island of Rotuma.Elsewhere Tuberculosis Hospital in Tamavua, with 313 beds, regulations require attendance of Fijian children between the the Mental Hospital at Suva, with 100 beds, and the ages of 6 and 14 if there is a school within three miles of their home.Education is free in the district schools, and fees may be Fiji Leprosy Hospital in Makogai, with 750 beds. waived in others for the poorer families. The sanatorium and the leprosy settlement have In townships housing is controlled by the township boards, rehabilitation units.There are also 45 dispensaries. and in rural areas it is subject to the approval of local authorities The dental health service is organized through four on the advice of the health officer.Numbers of Fijian and main activities :the Dental Centre at the Colonial Indian labourers are employed to collect and cut coco -nuts at a great distance from their homes, and have only temporary and War Memorial Hospital, the School Dental Service, often unsatisfactory living quarters.There is now a development the Dental Health Education Programme, and the plan for low -cost housing in such circumstances. Dental School.Where possible,assistantdental practitioners tour the country districts and a mobile Health dental clinic is on order. The health services are organized and headed by There are maternity wards in all the hospitals, the Director of Medical Services, who is assisted at and one of the mission hospitals is reserved entirely headquarters by a deputy director, a nursing super- for this work.Ante -natal clinics are held in the intendent, a chief health inspector, and clerical and hospitals, and in rural areas similar clinics are con- accountingofficers.TheDirectorisexofficio ducted by health sisters or locally trained nurses. chairman of the Central Board of Health, which One health sister is fully occupied on school health advises on all health matters and holds executive duties in the Suva area, and other nurses are placed powers in areas where there are no local authorities. at strategic centres.Mobile child welfare units oper- Twenty -twolocalauthoritiesareresponsiblefor ate from Suva and Lautoka. carrying the public health ordinance into effect, and There is no special provision for the chronic sick, they also undertake town planning and subdivision except in the case of tuberculosis and leprosy.Homes of land in their areas.For administrative purposes for the aged are organized by a private society for WESTERN PACIFIC REGION 357
Europeans, and by government administration on a of Medical Services, who is chairman of the Advisory district basis for Indians.The Fijian social system Board.In the clinical years the teaching is carried provides its own care of the aged.All factories out almost entirely by the staff of the Medical Depart- are subject to medical inspection and are compelled ment on a part -time basis.In 1955, there were by law to install medical and first -aid equipment. 92 medical and 28 dental students.Teaching is The control of communicable diseases is based on given in English.More and more emphasis is being the central epidemiological service at Suva.There laid on preventive medicine; the students receive are full port health services at Suva and Lautoka, three series of lectures during the medical course. and also at the Nadi Airport.Internal control is Post -graduate and refresher coursesareheld on part of the regular medical services. various aspects of public health, nutrition, filariasis, A tuberculosis survey was begun in 1950 and tuberculosis, leprosy, midwifery and maternal and completed in 1953.The BCG programme, which child health.Provision has also been made for was planned as part of the survey, was continued training some 250 local nurses, and courses are in 1954, when a mass miniature x -ray unit came held for most types of auxiliary worker, such as health into operation.By the end of that year there were inspectors and technicians. 392 beds in recognized tuberculosis wards. Progress has been made in environmental sanita- As early as 1886 it was decided to institute a course tion, and piped water supplies are provided in all for auxiliary medical practitioners in the area, and towns and in many villages.The central area of a three years' course of hospital training was started Suva has an ocean outfall for sewage, and its environs at Suva.In 1928 this school developed into the depend on septic tanks.Other populous areas have Suva Central Medical School, and its doors were septic tanks or bucket systems, and the rural areas thrown open to students from many islands of the are dependent on deep pit or bore -hole latrines. Pacific.The graduatesare known as" assistant There are protected catchment areas for the larger medical practitioners " and they give valuable service towns, and in any case of doubt chlorination is in these widely scattered areas.The course was adopted. extended to four years in 1931, and a fifth year was The general impression gained from the reports added in 1952. of the Medical Department is that the inhabitants The Medical School is a Fijian institution financed are taking an increasing part in their health services by the Fijian Government and administered by a and are co- operating in environmental sanitation principal under the general direction of the Director work.
FRENCH POLYNESIA
French Polynesia has five principal archipelagos -the Society The climate is hot and damp, but not unhealthy, and although Islands, the Marquesas, the Tubuai, the Tuamotu and the the islands are mostly mountainous they are also fertile.Copra, Gambier Islands -lying in the South Pacific, with a total area tobacco and vanilla are exported and coco -nuts, breadfruit and of 3998 square kilometres and a total population estimated other fruit are also produced.To a large extent the population at 73 000 in 1956.The capital is Papeete on Tahiti in the subsists on wild cattle and hogs. Society Islands.All the archipelagos have their own admini- The Tubuai Islands, also known as the Austral Islands, are strative districts. another volcanic group lying about 530 kilometres south of the Tahiti is one of the Windward group of the Society Islands. Society Islands.Here some 3921 Polynesians live in an area Its 640 square kilometres and 24 820 population make it the of 297 square kilometres.Tubuai, which is 10 kilometres long, largest and most important island in French Polynesia.Moun- is the site of the chief town of Mataura; it is the largest island, the tains extend over most of the island with four prominent peaks others being Rimatara, Rurutu, and Raivavae.Despite their rising to about 2330 metres in height.The climate is healthy general mountainous terrain, these islands are fertile, growing with an annual mean temperature of 30° C.Fruits, copra, pandanus, ironwood and coco -nut trees, and producing coffee, sugar -cane, vanilla, phosphates and pearls are the chief products arrowroot, some copra, and livestock. of the island.The indigenous population is Polynesian. The Tuamotu Islands, or Low archipelago, are a coral group The Marquesa islands, which are of volcanic origin, lie some of 854 square kilometres and 5127 inhabitants, which lie about 1186 kilometres north -east of Tahiti.They cover a land area 480 kilometres south of the Marquesa Islands.Some 80 atolls of 1240 square kilometres and have a population of 2988 Poly- are included in this 2000 -kilometre chain of small, flat islands. nesians.There are two groups of islands: the southern cluster, Rangiroa is the largest of the islands, and Fakarava is the most called the Mendana Islands, comprises the islands of Hiva Oa, important.Pearl shell and copra are the chief products, and Fatu Huku, Tahuata, Motane and Fatu Hiva; while the northern coco -nut, pandanus and breadfruit trees grow in abundance. cluster comprises the islands of Nuku Hiva, Hatatu, Eiao, The last group -the Gambier Islands, or the Mangarevas- Motu Iti, Ua Huka and Ua Pou. Nuku Hiva is the largest are another coral group in the South Pacific comprising about and Hiva Oa, with the capital Atunona, is the second largest. 19 square kilometres and 6696 inhabitants, all Polynesians. 358 FIRST REPORT ON THE WORLD HEALTH SITUATION
There are four islands and numerous uninhabited islets.Man - with 60 beds, at Taichae (Marquesa Islands), with gareva Island is the largest and the only important one of the 10 beds, and at Taravao (Tahiti), with 30 beds; a group.Its chief village is Rikitea, rising in hilly terrain up to some 430 metres.As in most of the other islands of the centre for lepers at Mahina (Tahiti), with 130 beds; South Pacific, copra and coffee are produced, pearl diving being and a private hospital in Makatea, with 30 beds. almost the only other occupation. Scattered throughout the islands there are 23 dis- pensaries and clinics. Health Each hospital and medical care centre has a mater- nity section and a centralized maternity and child In November 1843, when the first troops arrived in health service is being developed.The treatment of Tahiti, a health service was started, and in 1859 a children is carried out by a medical officer.The main religious institution was giving assistance to poor chronic diseases aretuberculosis, leprosy andfil- patients. A hospital was built in Papeete in 1884, ariasis.Tuberculosispatients receive treatment in and since that time various hospitals and dispensaries hospital centres and there are special institutions for have been constructed. lepers.In Papeete there is also a home (with 40 beds) Nearly 50 per cent. of the French settlers live on for aged people.One industrial firm, the Phosphate the island of Tahiti and most of the medical officers are Company in Makatea, has two medical officers and in the capital.The estimate of the general birth maintains a hospital.There is one mental hospital rate was 47 in 1956; the death rate was 10.8; and the in Papeete. infant mortality rate appears to have fallen during As regards environmental sanitation,practically the three years 1954 -56 from 106 to 80.The head all the inhabitants of the High Islands are amply of the health service of the French settlements has supplied with water.The inhabitants of the atolls been assigned to Papeete (Tahiti) and is responsible use rain -water gathered in tanks.Water collected for the general organization of health services for in the high valleys is usually unpolluted. the territory.On the health staff are 24 medical In the course of the year 1956 the chief activity of practitioners of whom 13 are working full time; 11 the Institute of Health has been a campaign against dentists, five pharmacists and 86 nurses (42 male). filariasis. A tuberculosis survey and a BCG vacci- There are also 24 midwives and 20 student nurses on nation campaign began in 1955.Of the sick in hos- thestaff.All medicalofficers,pharmacists and pital at Tahiti 3.4 per cent. are tuberculous, and it dentists hold a State diploma.Health education is seems that the figures are a great under -estimate of carried out in the schools and also in pre -natal and the total frequency of the disease.Apart from the post -natal clinics.Nurses and teachers carry the Research Institute, Papeete has one chemical and one service to the remote islands by means of broadcast bacteriologicallaboratory.One schoolhasalso talks. been provided for male and female nurses and The medical service consists of one general hospital midwives.The course for nurses is of two years' at Papeete with about 200 beds, including 30 for duration and that for midwives lasts three years. maternity care and 17 for mental health.There are A 300 -bed hospital in Papeete and a 15 -bed unit in also health centresat Uturoa (Windward Isles), the Marquesas are under construction.
GILBERT AND ELLICE ISLANDS
The territory of the Gilbert and Ellice Islands consists of the Primary education is largely in the hands of the missions, which Gilbert, Ellice and Phoenix groups, the Line Island, and Ocean provide free, rudimentary education in village schools for the Islands -amounting in all to about 37 atoll formations scattered bulk of the children.Education is compulsory between the over the central Pacific.They lie between 4° north and 11° ages of 6 and 16.Post -primary teaching is practically confined south of the equator, about half -way between Honolulu and to King George V School for Boys at Tarawa, which can take Brisbane, and have a total land area of 956 square kilometres. 120 boarders. A small number of students are sent overseas Of the total population of the territory (about 40 000), it was every year for secondary and higher education. estimated in 1955 that 28 000, including 150 Europeans, lived There is no serious housing problem. A construction scheme in the Gilbert Islands, the largest group.The Ellice group had was started in Tarawa in 1953 to provide new dwellings of per- 4574, with five Europeans, and the Phoenix group 1461, with manent materials under the direction of experts. 179 Europeans.Ocean Island has about 3000. Nearly all the cultivable land is planted with coco -nut, and Health copra is the principal agricultural product.The only manu- facturing industry is phosphate mining on Ocean Island, but The senior medical officer, with headquarters at there are a number of rural crafts. Tarawa, has an assistant medical officer, a qualified WESTERN PACIFIC REGION 359 pharmacist and two nursing sisters, and much time death rates were 99.0, 90.2, and 184.0.The crude is spent by the staff in touring the islands to supervise death rates were 18.1, 26.2, and 17.0. local activities.The central hospital at Tarawa has There are no piped water supplies, and water is a section for mental patients and an isolation block, obtained mainly from wells in the Gilbert Islands, and also provides training for an average of 18 nurses while rain -water iscollected in the Ellice group. and 10 dressers.The district hospital at Funafuti A few houses have bucket and sand latrines.Burning in the Ellice group is in the charge of a local graduate or burying of garbage is encouraged to overcome the of the medical school in Fiji.Local graduates sta- breeding of flies, which are prevalent on all the islands. tioned at the dispensaries on the larger islands, and There are no anopheline mosquitos, but mosquito dressers, visit the smaller islands as required. There are vectors of filaria are very prevalent.Insecticides are approximately 26 dispensary- hospitals in the islands, being introduced, as yet on a small scale. 12 of which are staffed by medical graduates from Fiji. The Gilbert and Ellice Islands participate in the General education on health is given by school- South Pacific Health Service, which has its head- teachers, but medical officers and health nurses also quarters in Fiji.Matters of policy and extension of take part during their visits to the various groups. servicesare formulated inconsultation with the Health education is part of the curriculum for the Inspector -General of the South Pacific Health Service. local training of nurses and dressers. Expert advice can be obtained from the specialists The birth rate in 1954 was: Gilbert, 36.6; Ellice, stationed in Fiji, and surveys are carried out from 59.1; and Phoenix, 58.2.The corresponding infant that centre as required.
GUAM
Guam is the largest and most southerly island of the Marianas, in agriculture, office practice, metal working and electricity. situated in latitude 13° north and longitude 145° east, with an The territorial college has expanded its programme to include area of 534 square kilometres.The south of the island is teacher training, and there are standard two -year college courses. mountainous; the northern part is a limestone plateau, with An increasing number of local teachers are trained in the United fertile but shallow soil.About 40 per cent. of the area is restric- States, but about 80 per cent. of the 362 teachers in public ted because of military installations. schools were recruited locally. A programme for adult voca- In 1956, the population census, excluding persons under tional education is being developed. military jurisdiction, was 37 419.About 32 000 of these are indigenous Guamanians, originating from the Micronesian people, probably of proto -Malayan descent but heavily mixed with Filipino, Japanese, Chinese and American Indian blood. Health The average number of persons per family is 5.61. As far as can be gathered, the permanent civilian population The Department of Medical Services of the Govern- occupies some twenty villages, ranging in size from 600 to about ment of Guam has a Division of Hospitals and a 6000 inhabitants.Agana, which before the war was the largest Division of Public Health. city, was destroyed, and is now partly rebuilt as the government The Division of Hospitals controls the modern centre, but has only 1200 permanent residents. The territory is divided into 13 districts or municipalities. 160 -bed tuberculosis hospital and the newly opened Agana, the capital, and Agat are the chief centres. general hospital(the Guam Memorial Hospital), The economy of the island has become largely dependent on which has 161 beds and includes surgical, medical, the activities of the government and military services.Very obstetrical and paediatric wards, a small psychiatric few of the population are now solely concerned with agriculture and fishing, and no large industry exists. ward,anout -patientdepartment,anoperating In 1956, nearly 8000 Guamanians were employed by military, theatre, a physiotherapy wing, and laboratory and government and private agencies. x -ray departments. Only about 15 per cent. of the total food requirement is The Division of Public Health shares administra- produced on the island, and importation from the United States tion, maintenance and housekeeping, and laboratory of America is very great, amounting to US $7 000 000 in 1956. Malnutrition is very rare, and when it does occur it is due to and x -ray facilities on a pro -rata basis with the Divi- ignorance rather than to poverty.Efforts are being made to sion of Hospitals.This division comprises sections encourage the production of more localfood,especially for sanitation, vital statistics and epidemiology, dental vegetables, fruit and domestic animals. hygiene,and nursing(thelast -named including Many of the territory's public schools have been rebuilt or modernized and more are being built.At the end of June 1957 maternal and child health and tuberculosis control). there were 21 public elementary schools and one high school. The central public health clinics and officesare The high school, which has nearly 2000 pupils, includes classes located in the Guam Memorial Hospital.Seventeen 360 FIRST REPORT ON THE WORLD HEALTH SITUATION small village health units, each headed by a Guama- The tuberculosis control programme consists of nian public health district nurse, who usually lives in case -finding with an x -ray mobile unit, examination her district, complete the facilities of the Public Health of contacts, follow -up of discharged patients and Division. BCG vaccination of the new -born, students, contacts There are two clinics on the island sponsored by and especially- exposed groups such as teachers and religious bodies and staffed by three physicians in all. hospital and public health employees.This pro- The general mortality rate has fallen rapidly from gramme was introduced in 1956; it has been accepted 10.4 to something less than 6 in 1956.The reasons enthusiastically by thepopulation and has had for this sharp decline are the increase in the percentage considerable value as an educative measure. of younger age groups.Only 13 per cent. of the total Regular public health clinics are held in all the population are above 45 years of age. A more impor- outlying villages.These village clinics are primarily tant factor in the decline is the improvement in intended for preventive work with infants and school- medical care and public health activities, including children, pre -natal cases and communicable diseases, sanitation and health education.The infant death but owing to transportation difficulties the physician rate has recently been computed with some accuracy, accepts all patients seeking his advice for examination, the present figure being about 39.Prematurity is by minor treatment, and referral to private physicians far the most important factor in infant mortality, and /or hospital, and he may also make home visits. and the majority of infant deaths occur in the first At the age of three months, all infants are referred week of life.The birth rate, although falling, is still as a routine measure to the public health physician high (38.5) and a steady increase in the population for examination before their immunizations are started may be expected during the next few years. against smallpox, diphtheria, pertussis, tetanus, typhoid The responsibility for dealing with vital statistics and poliomyelitis. for the whole island has been undertaken by a special Since July 1955 a qualified psychiatrist has been section of the Division of Public Health, and great employed on a part -time basis with the Department, advances have been made during the past two years. and has held weekly clinicsinthehospital. A The error in registration of births is now believed to Guamanian social worker attached to this service be less than 3 per cent.Since 1950 all deaths occurring has also been of much value as an interpreter.This without medical attention have been reported to the first step towards a mental health programme has authorities and the causes have been determined either now been followed by employment of a part -time by post mortem examination or by recourse to psychologist who, in co- operation with the psychiatrist, available medical records. is providing in- service training for all district nurses There are at present four physicians in private in mental health problems. practice on the island; all four are in general practice, A dental hygiene programme was started in 1955. and two of them also specialize in surgery and obstetrics. Dental hygienists visit all schools, giving lectures and Close co- operation with the Naval Hospital and its demonstrationsindentalhygiene,examiningall 21 physicians affords consultative services for the students and making appointments for treatment in civilian hospital in surgery, medicine, orthopaedics, thehospitaldentalclinic.Prophylacticfluoride radiology, dermatology,ophthalmology, neuro- treatment is also given to schoolchildren. psychiatry, urology and pathology. Great stress has been laid on all aspects of health The public health programmes include environ- education.Beyond the general programme, several mental sanitation, control of food -handling establish- films on such subjects as tuberculosis, sanitation and ments and hairdressers' and cosmeticians' premises, disease -carrying insects have been shown at village control of food products, water pollution, quarantine meetings,parent- teacherassociations,andother control, rodent and insect control.Law enforcement gatherings.Films have been used to accompany is kept to a minimum, great stress being laid on health campaigns for BCG vaccination and the co- operation education. of the press and the radio has been secured.
HONG KONG
Hong Kong consists of a number of islands lying close to the the Kowloon peninsula eight square kilometres, and the leased south -east coast of China (about 20° north) and the adjacent New Territories -including the remainder of the mainland territory on the mainland.The total area is just over 1000 square territory and the islands -910 square kilometres.The chief kilometres, of which Hong Kong Island itself, containing the physical feature of Hong Kong is its generally mountainous capital city of Victoria, comprises about 82 square kilometres, terrain, the highest peak being nearly 1000 metres.The climate WESTERN PACIFIC REGION 361
is subtropical with a mean temperature of 22° C.Rainfall public health in the New Territories, with the assistance comes mainly with the south -west monsoon, from May to of a medical officer seconded from theMedical August, and there are occasional typhoons.In 1931 the popula- tion was only 840 473, but it has been increasing enormously Department, who also supervises generally all the in the post -war years and is now (1956) estimated at 2 500 000, clinics, maternity homes and government medical of whom over two million live in the urban areas of Victoria and services in the New Territories.The Commissioner Kowloon.Over 99 per cent. of the population are Chinese, of Labour is responsible for health and sanitation in mostly Cantonese. Hong Kong's prosperity was founded on its entrepôt trade, factories, in which he is advised by an industrial but in recent years there has been a rapid expansion of local healthofficer,particularly on theprevention of industries and in 1956 some 30 per cent. of the exports were of industrial health hazards and occupational diseases. local manufacture.The largest group is the cotton textile Voluntary organizations are working in tuberculosis industry, covering most processes from spinning to finished control, blindness, deafness, leprosy, family welfare garments: a wide range of light industries is also represented. Heavy industry includes shipbuilding and repair yards, iron and family planning. foundries and mills rolling steel bars and rounds.Agriculture, The total expenditure of the Medical Department, fishing and some mining are the main primary industries. including subventions to voluntary bodies, was approxi- Education is not compulsory or free, but in many schools the mately 8 per cent. of the total government expen- fees are very low and in some cases are remitted entirely.There are 1150 schools with over 260 000 pupils; 37 per cent. of all diture for the year ended 31 March 1957, although schools are financed wholly or in part by the Government.The this does not include amounts spent on health services University of Hong Kong has a full -time residential strength of by the other departments mentioned above. 905. During 1956, 96 746 births and 19 295 deaths were registered, giving an estimated crude birth rate of 39.7 Health and a death rate of 7.9.There was a further drop in the infant mortality rate from 66.4 in 1955 to 60.9 Hong Kong's earliest hospitals were run by mis- in 1956. sionary bodies.The first government unit was the Apart from dispensaries, private nursing homes and Civil Hospital founded in 1859. A sanitary com- the Armed Services' hospitals, there are 28 hospitals missioner was appointed in 1882, and a sanitary board in the territory.Eleven of these are the responsibility was set up as a result of his recommendations.This of the Medical Department and the other 17 are run board continued in existence until 1936, when it was by various voluntary or private organizations, of which replaced by the Urban Council. seven receive substantial financial grants each year The responsibility for the administration of the from the Government.Treatment in government services safeguarding the public health in Hong Kong hospitals is generally free, and a total of 1999 beds are is shared mainly between the Medical Department, provided, while government- assisted hospitals have the Urban Services Department, the New Territories 2477 beds and private hospitals have 1172 beds. Administration (for the principal rural area of the Various government dispensaries provide a further territory), and the Labour Department.The Medical 98 beds for maternity cases, mainly in the New Department, under a Director and his Deputy, con- Territories, and there are 520 beds in private maternity sists of two main divisions - medical and health - and nursing homes.There is therefore in the territory each in the charge of an Assistant Director.The a total of 6266 beds for all purposes. A new 1300 -bed Department is responsible for the administration of government hospital is planned for Kowloon. all government hospitals, clinics, maternal and child The Director of Medical and Health Services has a health centres, and other health establishments; for staff consisting of 291 doctors, 1013 nurses, 71 phar- the study and control of communicable diseases; for macists and 3332 other workers. port health, and international health matters, vaccina- The Hong Kong College of Medicine was founded tion campaigns, etc.The Urban Services Department in 1887, and in 1908 was expanded into the University is concerned with questions of hygiene and sanitation; of Hong Kong.The Medical Department co- operates itadministers the public health laws relating to closely with the University in the training of medical environmental sanitation, food inspection, etc., and students.The main hospitals constitute centres for is also responsible for such matters as the control of clinical study and many members of the government hawkers, disposal of the dead, upkeep of public medical staff act as part -time lecturers. After qualifica- beaches and parks and playgrounds.The main work tion, medical graduates are required to do one year's of this Department is concentrated on cleanliness and post -graduate work under supervision before registra- hygiene and most of the staff are engaged on street tion, and many posts are made available for this cleaning, removal of refuse and related duties.The purpose in the government hospitals.The training New Territories Administration isresponsible for of nurses,healthinspectors,healthvisitors and 362 FIRST REPORT ON THE WORLD HEALTH SITUATION technicalassistantsisalsoconductedin Hong Malaria is no longer a problem in Hong Kong, Kong. because of the active anti -larval measures, which The general dental service is staffed by nine dental protect practically the whole population. officers, and in addition the school dental service has The vast majority of leprosy patients are treated six officers for the 50 000 schoolchildren who sub- at out -patient clinics, and infectious cases are cared scribe to the service. for in the Hay Ling Chau Leprosarium.Systematic In the years 1953 -56 the territory remained entirely attempts are being made to rehabilitate arrested cases free from the six quarantinable diseases and there were of leprosy,with moderatesuccess.It has been no significant outbreaks of any other notifiable com- possible to accommodate a certain number of such municable disease. cases in resettlement estates. Owing to the enormous increase of population In maternal and child care, the government mid- since 1945 (including some 700 000 refugees) and the wiferyservicehas35districtmidwives working resulting appalling overcrowding, tuberculosis has from 19 widely scattered centres in the urban areas and become a serious problem.However, excluding the in the New Territories.Twelve centres, all in rural immediate post -war years, when statistics could not areas, have maternity homes attached, with a total of be regarded as reliable, the mortality rate for 1956 was 98 beds.The remaining centres provide a domiciliary the lowest on record (13.6 per cent. of total deaths). service only.Furthermore, maternal and child health Ambulatory chemotherapy was started in the chest clinics provide the public with free ante -natal, post- clinics in 1950; since then the scope and magnitude natal, infant and child welfare services.During 1956 of this service has steadily increased and it has now five centres and 14 sub -centres holding clinic sessions become the spearhead in the control of the tuberculosis provided these services. problem. The Hong Kong Anti -Tuberculosis Associa- As regards environmental sanitation, a new reservoir tion (in its Ruttonjee Sanatorium) and the Tung Wah was completed recently, but the water supply is group of hospitals maintain beds for conventional stillinsufficient.The water -borne sewage -disposal treatment.The BCG vaccination campaign (started systemstillservesonly a portion of the urban in 1952 under the sponsorship of UNICEF and WHO) area, but isconstantly being extended.There is continues,with emphasis on new -bornchildren. an extensive system for the collection and disposal Radiographic service for periodic checking isavail- of night -soil.The Government has now entered on able for all civil servants annually, and all teachers a large programme to provide low -cost housing, are similarly checked before taking up their posts. both of the conventional type and in the form Arrangements are also made to x -ray any workers of multi- storey re- settlement estates in which over whose employers are prepared to guarantee paid sick 200 000 people had been re- housed by the end of leave to those with active disease. 1956.
JAPAN
Japan is situated in the North Pacific and consists of four of food.Textile manufacture is the main branch of industrial large islands and many small ones with a total land area of production, but iron and steel are also important. 369 766 square kilometres.The main islands are traversed Education is free and compulsory up to the age of 15, and by a range of high mountains with lateral spurs.Many of attendance for a further three years in high school is optional. these are volcanic, and the country as a whole is subject to Japan has six main university centres, with a total of 499 uni- earthquakes.The climate ranges from humid subtropical to versities and colleges both public and private; these were humid continental; most of the land is well watered and the attended by 531 613 students in 1955. warm ocean current makes the northern part relatively mild. Only one -sixth of the surface is suitable for cultivation, because of the many mountains.At the 1954 survey the total population Health was estimated at 88 293 000 (89 274 900 in 1955, and the pro- visional figure for 1956 is over 90 million).The density is At the national level the responsibility for the public nearly 241 per square kilometre. health programme rests with the Ministry of Health The main occupation of the people is still agriculture, in which and Welfare.The administrative machine is operated some 17 million are engaged; but industry, which at present employs five million workers, is increasing considerably.Rice through a secretariat and seven bureaux, which is the largest crop, and its cultivation occupies more than half include public health (with a division for environ- the area available.The fishing industry is an important source mental sanitation), medical affairs, pharmaceutical and WESTERN PACIFIC REGION 363 supply, social affairs, and a children's bureau. Indus- public healthservice,especially in public health trial hygiene is under the Ministry of Labour, and the nursing. School Health Service is conducted by the Ministry Deaths from tuberculosis continue to fall; in 1956 of Education.The country is divided into 46 pre- the rate was 48.6 per 100 000 population. A nation- fectures, each with its own governor, elected by popular wide ascertainment survey was made in 1953, by vote.Althoughtheseregionalauthoritiesenjoy means of random sampling, from whichit was considerable autonomy, most of the programmes in estimated that there were nearly three million suf- the health field are sponsored and subsidized by the ferers -a ratio of 3.4 per cent.- who needed medical national Government.The prefectural and municipal care, and a further two and a half million who required governments divide their boundaries into" health careful watching and medical supervision.In con- centre districts ", in each of which a local health sequence of these findings a new law has been pro- centre is established; there were altogether 783 of mulgated,requiringhealthexaminationsforall these centres in 1956 (788 in March 1957).For persons over six years of age.Further sampling geographical reasons most of the health centres have surveys have been made in subsequent years. branch units.They stand in the front line of the In planning the control of communicable diseases entire public health programme, carrying out both great attention has been paid to vaccination.Periodic personal and environmental functions, as well as inoculation covers smallpox, diphtheria, typhoid and health education.They were staffed in 1956 by paratyphoid, and whooping- cough, and special im- 5198 physicians, 8037 public health nurses, and 28 197 munizations are employed as required for typhus, other health staff as the official standard.In addition cholera, and certain other epidemic diseases. to work carried out in the centres, the public health The programme for maternal and child health has nurses made over two million home visits.The centres made good progress in recent years.It is noteworthy supervise medical examinations for the detection of that the proportion of deaths among the new -born tuberculosis, and preventive inoculation against com- is rising.The decrease in the maternal death rate, municable diseases. which was 1.6 in 1955 and 1.5 in 1956, is largely The birth rate in 1947 was at the abnormally high due to the intensive work in the health centres and figure of 34.3, and this was considered to be due to the increasing interest taken by rural community the restoration of family life after the war.The rate organizations.Schemes for handicapped children then started to decline rapidly, falling to 20 in 1954, have also made good progress in recent years, through 19.4 in 1955, and 18.5 in 1956.It is believed that the development of consultation clinics, short -term this change was due to the decreased marriage rate, orthopaedic treatment in general hospitals, and the the encouragement of birth control, and the pre- provision of rehabilitation in special homes. valence of artificially induced abortion.In any case, The occupational health programme employs 2350 the population of Japan has more than doubled inspectors, whose work includes the periodic inspection since the beginning of the century, and the death of health conditions, and personal examination of rate has fallen steadily over the years to 7.8 in 1955. workers.Silicosisis the major problem, and the The infant mortality rate for the same year was 39.8, regular medical examination of workers exposed to and expectation of lifeat birth was estimated at the dust is compulsory.Patients have the benefit 63.9 years for males and 68.4 for females. of a workmen's compensation scheme and free The most recent figures (1956) for hospital accom- treatment.The larger factories are obliged to appoint modation - including general, mental, tuberculosis, health supervisors. leprosy and communicable diseases - give the bed Local health centres have nutritionists on their capacity as 559 249 and the occupation of beds as staff, and training courses, as well as personal con- over 481 000.There is an acute shortage of beds sultations, are provided. A national nutrition survey and staff for tuberculosis and mental cases.The has been carried out every year since 1946, and its number of hospitals and clinics (general and dental) findings determine the nature and extent of the in 1956 was as follows : yearly programme. The problem of mental health has been attracting Hospitals 5418 General clinics 52846 public and professional attention to an increasing Dental clinics 25429 extent. A new mental health law was passed in 1950 which went far beyond the previous custodial legisla- As regards personnel, there is the usual difficulty tion and set up a scheme of community care and pre- caused by the concentration of medically qualified ventive work.Mental hygieneclinics have been men in the urban areas and the shortage of staff in the opened in the local health centres, and a number 364 FIRST REPORT ON THE WORLD HEALTH SITUATION of child guidance clinics have been provided in con- will increase this figure to 74 per cent. in urban nexion with the child welfare services. A selective areas and to 27 per cent. in the rural districts.The survey was carried out in 1954 with the object of Minister of Health and Welfare may offer subsidies obtaining basic data about mental disabilities.This for the establishment of water supplies or the acquisi- survey, which was carried out by psychiatrists, re- tion of land, up to one -fourth of the total cost. vealed that 1.55 per cent. of males and 1.41 per cent. There have been considerable developments since of females could be regarded as mentally sick and in the war in the re- establishment and extension of the need of treatment.Of these,3.9 per cent. were major research institutes.The Institute of Public under the domiciliary or institutional care of psy- Health now offers 10 regular courses and 13 short chiatrists; 4.8 per cent. were under other types of courses, most of its graduates being in the public professional care; and the remaining 91.3 per cent. service.The National Institute of Health, which were receiving no skilled attention. was founded in Tokyo in 1947, is concerned with Under the present law the cities, towns, and vil- providing a scientific background to public health lages are responsible for the collection and disposal administration.Its main tasks are related to field of night -soil, garbage and refuse, and for the control investigations and to the assay of biological prepa- of insects and rodents under the technical guidance rations, etc.More recently, national institutes have of the prefectures, and demonstration areas have been been set up to deal with the problems of leprosy, established.Under the existing system about 37 per food standards, and (in 1952) mental health.The cent. of the population are supplied by water -pipe National Institute of Nutrition was founded as early systems.New schemes are being developed which as 1920.
REPUBLIC OF KOREA
Korea is a peninsula on the Pacific coast of Asia, between 1949 a Ministry of Health was created; in 1955 it was 120° and 128° east and 34° and 43° north, with many islands off amalgamated with the Ministry of Social Affairs, the south and west coasts.The soil is fertile and the climate equable and healthy, with a marked rainy season in July and with a joint title: the Ministry of Health and Social early August. The amount of arable land is limited by the Affairs, which has three Bureaux -Preventive Medi- great mountain ranges which traverse the country.The mean cine, Medical Affairs, and Pharmacy.The health summer temperature is about 24° C and in winter the cold services are administered at three levels, with the continental climate supervenes, with temperatures as low as Ministry supervising the general policy.The pro- - 17° C.The total area (north and south) is 220 792 square kilometres. vincial governments are responsible for carrying out The population of South Korea at the 1955 census was national policies, mainly through the development of 21 526 374, with a density of 230 per square kilometre.(In healthcentres.Each provincialauthority has a 1944 the population of the whole peninsula was 25 million, with public health section to supervise the local health a density of 114, and the annual rate of increase was stated to be 1.42 per cent.)The ethnic grouping is uniform, closely centres and dispensaries. At present there are 17 health related with other Turanian races of North Asia.The people centres and 520 dispensaries, which undertake both of South Korea are mainly agricultural. preventive services and medical care for the poor. The staple foods -rice and fish -were produced in sufficient As funds become available the dispensaries are being quantity before the war; but the country's economy has not yet converted into health centres. A number of voluntary recovered from that disaster, and the people depend largely on assistance from abroad. agencies are also engaged in public health activities, Primary education is compulsory, and in 1955 there were their main contribution being in tuberculosis control 4220 primary schools with 2 877 405 pupils; 949 intermediate and in emergency work. schools with 475 342 pupils and 577highschoolswith The essence of the present situation is that the 260 613 pupils.For higher education there were, in the same year, 74 colleges with 90 000 students.Nine government medical services have been disrupted by war, and it has colleges and one graduate school have been united in Seoul to been difficult to make substantial progress on account form the National University. of financial and personnel deficiencies.Statistical data on a national scale are not yet available, but a Health sampling survey of 500 000 people has been made by Since the end of the war the health organization of the Ministry of Health, with the following results for South Korea has suffered some vicissitudes, but in the years 1954 and 1955: WESTERN PACIFIC REGION 365
1954 1955 ence of Japanese -B encephalitis in 1956 was 316, and Birth rate 37.5 35.6 that of diphtheria was 410. Death rate 21.0 20.6 Although some of the acute infectious diseases are Infant mortality rate 99.0 100.0 being brought under control, the chronic disease group- notably tuberculosis and venereal disease - The number of health personnel has been rising are still presenting problems, with 23 021 and 25 452 steadily during the past three years, but not at a pace cases respectively reported in 1956; 630 cases of leprosy to satisfy the need for a long time to come.In 1956 were reported in 1955 and 464 in 1956.To meet there were 6436 doctors, 1040 dentists, 2579 midwives, this serious situation, the Government has launched 2672 nurses, 1613 pharmacists and 2217 herb doctors. specific control programmes for these three diseases. It is stated that in the year 1955, 1.3 per cent. of the The principal emphasis during this period has been national budget was allocated to the health service placed on training of staff, especially in tuberculosis the per capita cost for health and medical services and venereal disease control.In leprosy work there being 52.89 Korean dollars (Hwan) (US $0.10) .1 has also been a significant development in the estab- By the end of 1956 there were 83 hospitals in service, lishment of a mobile clinic to carry out a survey and under the following administrations :the national to supervise treatment in the most heavily infected government hospitals (14, with a total of 2025 beds); areas. the provincial and other public hospitals (39, with a An intensive campaign of mosquito control has been total of 2481 beds); and the private hospitals (29, with carried out in the suburbs of cities, but the difficulties 1988 beds).In addition, there were six sanatoria, are admittedly very great in a rice -growing country. with a total of 1423 beds.There are ten institutions Attempts at fly control have reached the stage of the for rehabilitation services; nine of these are at present sanitary improvement of latrines and the introduction The able to undertake only vocational training. of larvicides. National Rehabilitation Centre in Tongnae is com- The National Institute of Health is serving as a pletely equipped for rehabilitation services. reference laboratory in bacteriology, serology and The health centres and dispensaries have a fixed virology and also as a vaccine and biological produc- programme for maternal and child health care, and tion centre.The National Chemistry Laboratory is a School this is regarded as a basic health service. reference laboratory for food and drug administration. health services are usually carried out by the health There are nine medical schools and 24 nursing centres in collaboration with the school authorities schools in South Korea, and refresher courses for concerned.Home visiting is hampered by the short- health personnel, including doctors, nurses and sani- age of nurses. tarians, are organized by the Ministry of Health Health education of the public is being carried out and Social Affairs. systematicallyatallthreelevelsof government. There are 56 waterworks in the large cities of South Special efforts have been directed to the control and Korea, supplying an average of 60 litres per person prevention of the major communicable diseases, and daily to 14 per cent. of the total population; the re- many voluntary agencies contribute to the success maining 86 per cent. of the population are dependent of the work. largely on wells for their water supply.Human and The successful control of communicable diseases animal excreta are widely used as fertilizers by farmers, has indeed been the most encouraging feature of and this custom complicates the sewage -disposal pro- health activities in South Korea during the past blem in Korea.However, efforts are being made to three years.In the years 1951 -53 inclusive the median educate farmers to use night -soil after it has been incidence for the three -year period was 3969 for treated by storage.In 1956, the construction of typhoid fever; 3349 for smallpox; and 923 for typhus. Tongyang Organic Fertilizer Plant was completed, For the year 1956, the corresponding figures were and a maximum daily output of 70 metric tons of reported to be 351, 9, and 92 respectively.The incid- fertilizer produced from bacterial digestion of mixed night -soil, garbage, beancurd and peat is expected in 1 1958 exchange rate the near future. 366 FIRST REPORT ON THE WORLD HEALTH SITUATION
LAOS
The Kingdom of Laos occupies the north -west part of former charge of graduate nurses, are situated at smaller French Indo- China.It is separated from Burma and Thailand centres.They receive seriously ill patients and arrange by the Mekong river.China lies to the north and Viet Nam covers the whole eastern boundary, giving no access to the sea. for their transport to the nearest hospital.In the On the south is Cambodia.The northern part in particular relatively large towns far from any hospital, the is very mountainous with deep valleys cut by the tributaries of dispensariesdonotaccepthospitalcases.The the Mekong. The area is 237 000 square kilometres.The severe cases are treated at home, and mild cases by mid -1954 population was estimated at 1 360 000, with a density daily attendance at the clinic. of six per square kilometre.The main occupations are agricul- ture, forestry and stock -raising. As regards personnel, there are 40 medical officers, There are approximately 900 primary schools in the Kingdom, some of whom have been trained at the Hanoi medical with nearly 40 000 pupils, five secondary schools with approxi- school; about 470 male nurses, who have received mately 1000 pupils, and one teacher- training college. six months' theoretical and between one and one - and -a -half years' practical training; and 95 female Health nurses, who serve in the hospitals.There are seven In 1953 the public health service was reorganized. midwives who trained for three years in the midwifery At first the Minister, who was medically qualified, school in Saigon, and almost all of these serve in acted as Director of Health and was assisted by a Vientiane.In the rural areas 247 midwives of limited deputy director.In1957, however, theMinister education have attended practical lecturesat the ceased to act as Director of Health.Instead, the hospital for at least six months.This training is post of Director - General was created.There are at encouraged, and itis planned to assign one rural present two deputy directors under the Director - midwife to each important village, where she will General.The main problems before thehealth perform first -aid duties and serve as a dispensary servicesare,first,totrain medical and auxiliary nurse in addition to practising midwifery. staff, as there is at present only one doctor per 50 000 Training of professional medical and allied personnel inhabitants; and secondly to create hospital centres in depends almost entirely on fellowships,especially the main cities, and to train nurses for hospital work in France.At present 12 students are registered and also for work in dispensaries within each province. in faculties of medicine in France and three midwives The third problem isthe general control of com- and two social workers are also studying there.Six municable diseases. students are registered at the Phnom -Penh School At the national level the Director -General, under the of Public Health. supervision of the Minister, is responsible for all In the control of communicable diseases, smallpox health problems.He is assisted by a deputy director, and cholera vaccinations are compulsory.They are who is in charge of the main hospital and deals with performed in the villages by nurses during their medical supplies.At the provincial level there is a visits.Special programmes have been planned for chief medical officer in charge of health services and the control of yaws and malaria. locally a head nurse takes care of the dispensary No special government measures have been taken under the provincial medical officer. to promote health education.The only available The exact birth and death rates are not known, health statistics are those provided by the provincial but the infant mortality rate is estimated at approxi- chief medical officers in their reports, dealing with mately 100 in the cities and at least 200 in the rural main diseases but not with vital statistics.No special areas. nutrition service has been set up, and the general A number of voluntary organizations, including the maternal and child health services are confined to the Laotian Red Cross in the capital and the Association large cities. of Laotian Women in the provinces, take an active As regards environmental sanitation, the water part in the health services. supply in Vientiane is insufficient, and supply trucks The main hospital in Laos is the Mahosot hospital have to be used: there are no water - supply systems in Vientiane, which has 100 beds.Secondary hospitals in other cities.Sanitary installations for the disposal exist in the provincial towns, and have between 40 and of excreta do not exist in the villages and are very 80 beds.Dispensaries, with 12 -20 beds and in the rare in the towns. WESTERN PACIFIC REGION 367
MACAO
The Portuguese Province of Macao lies on the south coast and equipment of hospitals and other establishments of China, between latitudes 22° 5' and 22° 13' north and longi- are covered by another fund. tudes 113° 27' and 113° 37 east.It forms a peninsula joined to the mainland by an isthmus, and includes two islands off the It is not possible to give any figures for vital sta- coast -Taipa and Coloana.The total area is 15.5 square kilo- tistics, since births are not registered, and neither metres, of which the mainland occupies 5.5 square kilometres general nor infant mortality rates can be established and is the more densely populated.According to the 1950 in the absence of complete records of over -all and census, the population numbered 187 772, of whom 96 per cent. infant deaths. were of Chinese origin and 4 per cent. were Portuguese.In 1954 -56 the population was estimated at approximately 400 000. No cases of quarantinable diseases have been The province is administered by a local Governor, whose recorded during the period under review, and there seat is the city of Macao, and who controls all the public has been no significant change in the general situation services. with regard to the principal diseases. The health services give constant attention to the Health control of malaria; apart from a control programme organized on a permanent basis, special sanitation The structure of the health services is based on a and insect control measures are undertaken at regular Decree of 1945, under which the health services in intervals.There is also a permanent venereal disease the Portuguese overseas provinces were reorganized. control programme, and a similar programme for A central Health Department is in charge of all the the control of tuberculosis is being started. services and various bodies, such as the Health and Maternal and child health services have been de- Hygiene Council, hospitals, laboratories, and special veloped during the period under review; pre -natal clinics units for the care of mentally disordered persons and have been established, and care of expectant mothers drug addicts, for social welfare and infant care, and is also provided in the dispensaries.Child -birth care for the control of leprosy and malaria.There is in the government maternity homes is free of charge only one district health service in the province - in for the families of governmentofficialsand for the city of Macao - and it is responsible for public needy persons.It has also been possible, with the health activities, for the improvement of social hygiene, help of the 42 graduate midwives (Chinese and for the control of endemo -epidemic diseases and for Portuguese),to organize a domiciliary midwifery the organization of medical care. service. Curative and preventive medical care, whether of a The Tong Sin Tong Benevolent Society does a general or of a specialized nature, is provided through great deal of home visiting of mothers and children. government or private hospitals, dispensaries and The government childwelfareorganization runs health units.In 1956 there were the following gov- nurseries,crèchesand reformatories.The Santa ernment establishments: two general hospitals, one Infancia Hospital provides meals and medical care military medical station, one venereal disease clinic, for children in need of them. and 20 out -patient dispensaries for general medicine, The Government is fully aware of the importance chest diseases, ophthalmology and dentistry.Private of health education, and all the health services staff establishments subsidized by the Government con- carry out health education activities as part of their sisted of two hospitals, with a total of 1057 beds, normal duties. providing services for general medicine, paediatrics, There is a serious housing shortage in Macao. surgery, maternity, tuberculosis, infectious diseases, Urban development schemes include the building of mental disorders, drug addiction and cancer. new roads and the widening of existing ones, as The medical and health personnel consisted of well as the cementing or asphalting of their surfaces. 50 physicians, 40 dentists, five pharmacists, 87 nurses In the city area, filtered and chemically treated water (male and female), 186 auxiliary nurses, 42 midwives, is supplied to private houses and isalso available 19pharmaceuticalassistants,29healthvisitors, from 21 public fountains and from 20 other fountains, five x -ray technicians and two laboratory technicians. where it can be bought.Non -potable water for The percentages of the general government budget domestic purposes is provided throughout the Province and municipal budget allocated to the health services by 252 wells, which are protected against pollution. are 9.23 and 10.3 respectively.This money is devoted Almost the entire area of the city of Macao is served solely to the cost of running the services; construction by a main drainage system. 368 FIRST REPORT ON THE WORLD HEALTH SITUATION
FEDERATION OF MALAYA
The Federation of Malaya, an independent country within Health the British Commonwealth, occupies the southernmost part of the Kra Peninsula as well as the southernmost part of the Until 1957, when the Federation attained indepen- continent of Asia.Jutting into the China Sea on the east and dence, the Federal Medical Headquarters was res- the Strait of Malacca on the west, some 1200 kilometres in ponsible to the Member for Health (later the Minister length and 320 kilometres in width at its widest, it borders for Health), and directly responsible for the institutions Thailand on the north and is bounded by the Straits of Johore (or Singapore) and the island of Singapore on the south. for leprosy, mental diseases, quarantine and port Extending between latitudes 1° and 7° north, and longitudes health.Each state and settlement had its own medical 100° and 105° east,its climate is characterized by a fairly organization responsibletoitsown government, uniform temperature, averaging from 21° to 32° C, and high which in turn had executive control of the medical humidity, the average annual rainfall being about 250 centi- services.The Federal Government was the advisory metres.Its area is 131 285 square kilometres, with a population in 1956 of 6 251 649; of the latter the Malays constitute the and co- ordinating medium, and as shown inits majority, with Chinese (44 per cent. of the total), Indians, annual budgets it stimulated greater interest in the Pakistani and Europeans forming the principal minorities. health needs of the Federation.In 1956, for instance, Economically the Federation enjoys a favourable position, the health budget was M $56 561 984 (US $18 667 321), and should continue its prosperous development unless there is a serious drop in the world prices of rubber and tin, its primary or 9.4 per cent. of the total budget, in comparison export items, which constitute 80 per cent. of the total value with M $43 631 000 (US $14 399 670),or1.6per of exports.In 1955 rubber exports represented no less than cent., in 1952.In 1956 this provided a per capita one -third of the world production.The main agricultural expenditure on health of M $9.70 (US $3.20). products are rice (amounting to 45 per cent. of annual domestic Urban health is becoming increasingly associated consumption), sweet potatoes, tapioca, maize, sago, groundnuts and pineapples.Fish, the most important protein element with local government.The municipalities, being in the local diet, is marketed almost entirely by Chinese, although independent of state and settlement governments, fishing is carried on by the Malays.The Federation's principal have complete control over theirfinances,their imports are rice and other foods, beverages and tobacco, mineral staff and their programme of works, while the town fuels, chemicals and textiles. A rubber replanting scheme, introduced in 1952 to rehabilitate boards' staff are financed by the state and settlement the industry over the next six years, has since been expanded. governments.Health officers in municipalities and A grant of £35 000 (US $98 000) was approved in 1954 for re- town boards have supervisory and advisory roles. search on and development of cocoa production.Grants The work undertaken in both municipalities and totalling £47 558 (US $133 162) were approved for the mecha- nization of rice cultivation. Similar grants were made to increase town boards includes maternal and child health, off -shorefishingthroughmechanization andtrainingof sanitation, supervision of markets and street trading, personnel. rodent control and investigation of infectious diseases. School administration is the concern of the state and settle- The local committees of town councils are responsible ment governments, each of which has its respective education for health and sanitary care. department.The great majority of the schools are financed by the Federation, either directly or through its grants -in -aid. The vital statistics of the Federation in 1956 were Other schools, also subject to government registration and as follows: birth rate, 45.5; death rate,11.3, and inspection, are those sponsored by missions; they are mainly infant mortality rate, 74.0.Principal causes of death for girls and the language of instruction is English. appeared to be fevers of unknown origin, infantile Housing may be classified as follows: (a) the housing of convulsions, pneumonias, gastro -entiritis and colitis, government servants and of estate and mine workers, standards for which are enforced by legislation and administrative action; and pulmonary tuberculosis. (b) the housing of rural communities, in which progress is made In 1956 there were 30 general government hospitals by the slower method of education; and (c) private houses in with bed capacity for 8638 patients; 38 district hos- urban areas, where building is controlled to prevent sub -standard pitals with a further 8093 beds, and 162 private results.In contrast to the rural dwellings of the Malayan subsistence farmers, which require little improvement, those hospitals with 6416 beds.There were also 4200 beds of the Chinese farmers are usually unsatisfactory.However, in two mental hospitals and 3419 in leprosy institutions. the great need is for more suitable urban housing, which in High priority is given to the rural health scheme, 1954 led to the Federal Town Planning Department schemes for which will affect well over half the population of establishing 35 new villages.This move was inspired by the successful establishment of a satellite town near Kuala Lumpur, Malaya; plans include the provision of a midwife which by 1954 encompassed over 600 completed houses with for every 2000 persons, a sub -centre for every 10 000 accessory roads and services. persons and a district centre for every 50 000 persons. WESTERN PACIFIC REGION 369
A pilot scheme to build eight rural district health for administrative and teaching posts, and to develop centres in eight different states has been launched, a training programme for midwives; there is now and during 1956 four had been completed and opened. provision at the Regional Nurses' Training School Contributing to the Government's expansion pro- in Penang for the training of 250 nurses and 25 male gramme for rural health services, the rural health nurses, and the training of assistant nurses is progress- training school at Jitra was completed and officially ing in all states and settlements. opened in early 1956.Two courses were held during In recent years the Federation has been free from 1956, attended by 48 students, who were organized serious infectious diseases.Tuberculosis, however, into teams and comprised midwives, assistant nurses, is causing increasing concern, especially since there sanitary overseers, dispensers and male nurses.The isa serious shortage of accommodation forin- personnel trained at this school will ultimately staff patients.Thereisalso need for more complete the rural health centres.Rural health facilities at the information on the extent of this disease.In the end of 1956 were as follows : rural areas worm infestations, diarrhoeas and dysen- teries are not uncommon, although the incidence Dispensaries 151 Mobile dispensaries 85 of malaria is falling.Diphtheria infection remains Maternal and child health clinics 72 high, and anaemias arestillthe chief nutritional Maternal and child health sub -clinics 518 problem.In 1956, 8528 cases of tuberculosis were Red Cross teams in operation 18 reported, 4017 of dysentery, 472 ofd iphtheria and 931 St John's Ambulance teams in operation 16 of typhoid fever.Sanitation in crowded urban areas Mission stations doing medical work . . 17 needs improvement, and some rural water supplies The medical and health staff in the Federation are of doubtful quality. in 1956 were as follows : A yaws control campaign, begun in 1953 in Kelantan Government Private and Trengganu, was continuing in 1956, and a BCG authorized actual estab- staff campaign which was started in 1951 is now carried lishment on throughout the Federation, particularly in schools Registered medical practitioners 393 266 451 and infant welfare centres, and in certain rural areas. Research medical officers 19 18 - Three thousand beds are provided in government Dentists (qualified) 68 52 33 hospitals for the treatment of acute tuberculosis, Dentists (registered) - 1 505 Pharmaceutical chemists 4 4 - and the Lady Templar Tuberculosis Hospital at Nurses of senior training 1301 935 198 Kuala Lumpur was completed and functioning in Partially trained nurses 250 218 - 1956. A tuberculosis settlement at Pulau Jerejak, Assistant nurses 995 915 Penang, with 400 beds, and a tuberculosis camp Midwives 785 641 - Sanitary inspectors 187 159 - at Kota Bharu, Kelantan, with 98 beds, provide Laboratory assistants 94 79 - further accommodation; there are nine tuberculosis X-ray assistants 36 33 - and chest clinics in the country and one convalescent Pharmacists 17 6 44 home for tuberculosis patients. Hospital assistants 1086 1 025 - Dental technicians 37 27 The Special Federation Committee on Nutrition Dental nurses 125 95 - has initiated a limited number of school feeding programmes in some states and settlements.Estate Medical education is effective, though on a small labourers' and mine -workers' health was cared for, scale.The medical school - part of the University in accordance with the Labour Code, by estate medical of Malaya in Singapore - offers a six-year course practitioners under Government Health Department followed by a one -year internship in approved hos- supervision. pitals.Upon graduation full registration is accorded The Federation maintains an institute for medical by the Federation and recognized by the General research administered as a branch of the Medical Medical Council of the United Kingdom.About Department, with its main buildings in Kuala Lumpur. 50 doctors qualify annually.Dentists and phar- In1954 new laboratories for the study of virus macists are also trained in the University.In 1950 diseases were added to those investigating yellow a programme was begun to improve the standard fever vectors, scrub typhus, filariasis, malaria and of basic and graduate nursing education and the tuberculosis, as well as nutrition problems such as quality of nursing services, to prepare local nurses the enrichment of rice. 370 FIRST REPORT ON THE WORLD HEALTH SITUATION
NETHERLANDS NEW GUINEA
After the war, Netherlands New Guinea became a separate centres and are regularly on tour to the areas assigned residency, the capital being Hollandia.The area is about to them. 416 000 square kilometres, lying between 130° and 140° east; the island reaches the equator in the north and the 9th parallel The territory is divided into 23 medical districts in the south.The total population was roughly estimated at under the supervision of qualified medical officers, the end of 1955 at 700 000, giving a density of about 2 per square and this number is being extended as circumstances kilometre, with, however, great local differences.The approxi- allow.Sixteen of these districts have full hospital mate race distribution for areas under regular administration is:281 000 registered and 100 000 unregisteredPapuans, facilities, while seven have out -patient departments 16 000 Asians and 14 000 Europeans. with hospital accommodation for a small number In the rural areas, the Papuan belongs to a village community, of patients.The hospital at Hollandia, which was bound by tradition, which determines social relations and the used mainly for indigenous patients, was closed in rights and obligations of its members. A community of this the middle of 1956, and a central hospital for indi- kind has its own system of administration and justice and its own holdings in land, crops, etc.Mutual assistance is an genous patients at Hollandia -Binnen has been esta- important feature in all these traditional communities.The blished, where the training of staff has been centralized. adaptation of the Papuan to modern civilization is being steadily The hospital for Europeans is at Ifar.The physicians accelerated. working in this hospital go on regular tours to the The indigenous economy is agricultural and the principal export is copra.Rice, maize, vegetables and fruit are grown other residency hospitals, six of which have facilities mainly for home consumption.Some crude oil is also produced. for major surgery. The soil is generally poor and local agriculture is mostly shifting At the end of 1956 there were 32 Papuan infant wel- cultivation.Sago is the principal food crop in the lowlands. fare nurses, working in villages under the supervision Various agrarian projects have been started with the object of of European nurses.The Papuan nurses have wide combining rice production with cattle breeding. On account of the level of development of the country and responsibilities ranging from medical treatment to the wide dispersal of the population, education is not yet com- advice on housing and nutrition, and each supervises pulsory.By the end of 1954 the number of Papuan children areas with populations of up to 9000 people. attending school was about 35 000 -approximately 46 per cent. An estimate for the controlled areas suggests a of the children between 5 and 12 in the registered population. Except in a few town schools, education is free.Government birth rate of about 55, a death rate of 45, and an and private sources, primarily missions, make equal contributions infant mortality of at least 350.Differences in infant to school teaching. mortality from district to district are mostly connected There is still a great shortage of housing and the lack of skilled with the prevalence of malaria. labour is a serious handicap.Social welfare is, in the first instance, the responsibility of the churches and private organiza- Tuberculosis was introduced into New Guinea tions.There is now a section for social welfare in the Depart- comparatively recently.The present distribution is ment of Social Affairs.Surveys undertaken in 1953 showed mainly in the centres of population.In the coastal that in many regions the people's diet was deficient, especially area BCG vaccination was started in 1956, supported in protein. by measures for health education to make people understand the danger of infection and the means of Health prevention. X -ray equipment is also available in the In 1950 the Department of Public Health, Social main hospitals. and Cultural Affairs was established, and the public Leprosy wasapparentlyintroducedinto New health service became a division.In 1953 it became Guinea in 1903, and its spread since then has been a separate department with its own divisions.The considerable, especially in the western areas, where a central office of the department is at Hollandia and figure of 10 per cent. infection is given.Campaigns there are divisional offices in various other areas. are also being conducted against yaws and filariasis. The head of the central department is a Director, There is no medical school in the territory and med- assisted by a medical and administrative staff. Medical ical students study overseas.There are three -year organization consists of divisions of hospitals, phar- courses for Papuan nurses for the New Guinea macy, health education, the major communicable Certificate at Hollandia and Sorong.The course, diseases,dentistry and the training of personnel. started in 1954 to train village nurses for maternal Government medical officers are stationed at district and infant care, is being steadily developed. WESTERN PACIFIC REGION 371
NEW CALEDONIA AND DEPENDENCIES
New Caledonia is a group of volcanic islands which has In 1956 there were one main hospital, 13 medical formed part of the overseas territories of the French Union centres,19 nursing homes, eight dispensaries, and since 1946.The islands comprise 18 000 square kilometres of land, lying in the south-west Pacific, in Oceania, about 1125 seven private institutions.The number of general kilometres east of Queensland, Australia.New Caledonia, beds amounts to approximately 1150, including the with its capital Nouméa (12 000 inhabitants), is the largest and 341 at the general hospital; and the special units most important of the group, which includes the dependencies include beds for maternity cases (59), tuberculosis of the Isle of Pines, the Wallis Archipelago, the Loyalty Islands (129), communicable diseases (27), leprosy (378) and of Maré, Lifu, Uvea and some smaller islands, the Huon Islands, Futuna and Alofis Islands, the Chesterfield Islands, Walpole mental diseases (74).Some provision is also made Islands and the Belep Islands. for the aged and infirm (110 beds). Racially the indigenous population of the New Caledonia In 1956, the government services included 24 doc- Islands are a mixture of Melanesian and Polynesian stocks, while tors, one dentist, one pharmacist, one administrative the contract labourers are predominantly Javanese and Ton - kinese.The estimated population for 1956 may be divided as officer, 67 nurses, five midwives and 41 assistant nurses. follows: indigenous, 36 000; European, 23 000; Vietnamese, In addition to those in government service, there 4000; and Indonesian, 3000, making a total of 66 000.The were 13 private doctors, seven dentists and six phar- sparse population of 3.5 persons per square kilometre is largely macists. due to the mountainous nature of the islands. New Caledonia Island is 400 kilometres long and 50 kilo- Health education is promoted by a voluntary com- metres wide, with interior plateaux and coastal plains separated mittee in consultation with a government medical by mountain ranges which reach a height of 1650 metres.The officer, and liaison is maintained with the National climate is healthy with an average temperature of 24 ° -27° C. Centre for Health Education in France.Posters, The mean annual rainfall is 110 centimetres.Hurricanes expose radio talks and other methods of education are used the inhabitants to periodic danger.The mineral resources are extensive although as yet comparatively unexploited.Apart at regular intervals in the villages. from the nickel and chrome mines, there are deposits of cobalt, The dental service is provided partly by private manganese, iron, mercury, antimony, cinnabar, gold, silver, lead dentists and partly by public dental surgeons who and copper. A considerable amount of smelting is carried on travel from place to place with their equipment. at Yaté and Doniambo.There is a big livestock industry and This service is greatly appreciated by the people and there are coffee plantations.Nickel, chrome and coffee are the principal exports.The Kauri pine, coco -nut trees and the periodic visits bring in a large number of patients. tree ferns are also found to a considerable extent. The maternal and child health work forms a part of the general health service, with pre -natal and post- natal consultations and infant health care services. Health The school medical service extends to all the public The establishment of the health service in New schools, and itsprovisions include x -ray control Caledonia and its dependencies goes back to 1853. and tuberculin- testing in addition to periodic medical The organization, which was under the supervision examinations, which permit a close follow -up of the of the French Naval Ministry, passed to the Ministry child's health.There is no serious nutritional pro- for the Colonies and later became practically indepen- blem in New Caledonia.In some villages lack of a dent under the authority of the director, responsible balanced diet has been observed with evidence of to the High Commissioner of theRepublic.In vitamin C and D deficiencies. certain international and maritime relationships, the Apart from leprosy and tuberculosis, both of which French Overseas Ministry is responsible. are being studied, New Caledonia has no serious The health service is under the general control of epidemic diseases.It is fortunately free from malaria a department at Nouméa with a director of health and its medical problems, in spite of its position, are and two deputies - technical and administrative. essentially those of temperate zones. BCG vaccina- General health services include medical inspection tion is being introduced. of schools.Each of the 12 districts is under the direc- Environmental sanitationiscarried out by the tion of a resident medical practitioner and has a municipal health department.Running water exists medical centre and a dispensary.There are also in practically all the townships, and analysis of water certain special services, which include mobile units samples and water purification are undertaken where for dental work and for medical assistance to the necessary.Refuse and excreta disposal iscarried indigenous population. out by incineration and septic tanks.The Director 372 FIRST REPORT ON THE WORLD HEALTH SITUATION of Health undertakes the supervision of housing. Since 1956 a school for the training of nurses and Campaigns against rat infestation are in operation. midwives has been establishedat Nouméa.The Laboratory research is undertaken at the Institut course of study lasts for two years and covers the Pasteur at Nouméa. whole range of nursing.
NEW HEBRIDES
The New Hebrides lie between 13° and 21° south and 166° by a mission body).Secondary education is, however, nor- and 170° east, and form an irregular double chain about mally provided by sending promising pupils either to New 704 kilometres long with a total land area of 14 763 square kilo- Caledonia or to the Solomon Islands.Students from the various metres.Between the Banks Islands and the Torres Islands in mission schools are the chief source of New Hebrideans for the north and the islands of Erromango and Tanna in the south, training as clerks, wireless operators, teachers, and auxiliary there are a number of large islands- including Santo, Malekula, medical and health personnel.The 1955 budget of the Joint Efate, Ambrym, Epi, Aoba, Pentecost and Maevo -and some Administration included for the first time a small subvention 60 small islands and islets.Santo and Malekula are particu- towards the cost of education, to be shared equally by the larly mountainous and rugged, parts of Santo rising to over two national administrations. 2000 metres, and there are active volcanoes on three of the The aged and infirm are cared for by the indigenous people islands.The archipelago is generally well- watered, and the themselves, and social welfare work is mainly undertaken by larger islands have several small rivers navigable for some missions, subsidized to some extent by the administration. distance by boats and small motor craft.There is a hot and wet season from November to April, but the cool season, from May to October, is healthy and pleasant. Health The people are mainly Melanesian, but there is also some admixture of Polynesian, especially in the east and north.The The New Hebrides have no fully constituted joint total indigenous population at the end of 1956 was estimated to medical service, although there is the nucleus of a be 48 725, while the non -indigenous population numbered ap- proximately 4400.Of the latter 3910 were of French and 490 Condominium MedicalService,forwhichlegal of British nationality (including some 1740 Asians and 670 Wal- provision has existed since 1938.Among its various lisians and Tahitians). functions theservicesubsidizes the treatment of The territory is at present divided into four large districts, New Hebrideans at national or mission hospitals each consisting of widely scattered islands.The chief town is Vila, on Efate, and the only other town is Luganville, on Santo. and maintains two sanitary squads, one at Vila and one Most of the population live in villages or hamlets varying in size at Santo, for mosquito control and general sanitary from 600 or so people to small collections of huts, and they work of limited extent.In practice, however, medical follow their traditional tribal system of organization.The main and health work is carried out by the two national occupation is agriculture, producing both subsistence and cash administrations separately, with considerable support crops.In spite of some increase in fisheries and mining, the economy of the territory is still based mainly on copra, the pro- from mission bodies.The Senior French Medical duction of which is affected by manpower; at present it is neces- Officer is also the Chief Condominium Medical Officer, sary to import labour, since the inhabitants tend to prefer and he isassisted by four medical officers.The working their own agricultural lands of which there is no short- British Medical Officer is assisted by five Assistant age, and the group of islands as a whole is underpopulated. The chief exports are copra, cocoa, coffee, and some timber, Medical Practitioners.There are also three Assistant and the chief imports are rice and petroleum products. Medical Practitioners under the Condominium admi- The traditional diet has been mainly vegetarian, supplemented nistration. by fish, or by meat obtained by hunting or the sacrifice of pigs. Other health personnel in the territory are:31 Yams are the staple food crop, but breadfruit, taro, bananas, nurses of senior training (15 in the French service, sugar -cane, paw -paw and other foods are cultivated.Those living in urban settlements or on plantations also eat beef 16 under missions); 17 midwives of senior training (either tinned or fresh), bread and rice, and these foodstuffs have (one in the French service, and 16 under missions); spread to the villages. over 40 locally trained nurses under missions; 44 Each of the administering authorities (France and the United locally trained dressers (one in the British service, Kingdom) subsidizes its own national system of education. Education is not compulsory, the fact that the islands and villages 11 under the Condominium, and 32 under missions); are widely scattered being a serious obstacle to school attend- two private dental practitioners; one locally trained ance.The French Administration has established four primary dental worker in the French service; and two sanitary schools, which are free and open to all, and with the help of inspectors, one mental hospital guardian, and one development funds new primary schools will be built elsewhere. The British Administration runs a primary school for children hygiene assistant, all under the Condominium. of all races in Vila.Both administrations subsidize primary Medical and health establishments in the territory schools run by missions, and there is one high school (also run in 1956 were as follows :five general hospitals (three WESTERN PACIFIC REGION 373
French, two mission) equipped to deal adequately Children in the public and private schools at the with all general medical and surgical cases, with a main centres of Vila, Santo and Lamap are examined total of 242 beds; nine cottage hospitals (three British, annually; a medical record isprovided for each oneFrench,twoCondominium,threemission) pupil, and vaccinations are carried out against small- equipped to handle less serious cases, with a total of pox and tetanus. 186beds; 42 dispensaries (two Condominium and Health education had not made much progress 40 mission), and one leprosarium run by a mission until recently, but following investigations by the body, with37patients. French authorities an attempt has been made with Expenditure on medical and health services in 1956 the assistance of the village chiefs to obtain direct amounted to £A116 200(US $260305),of which access to the people.An experimental area was £A 41 100 (US $92 070) was for the Condominium etablished in the village of Mele, close to Vila, service, £A 60 900(US $136425)fortheFrench and some progress was made in linking preventive administration and £A 14 200(US$ 31 810)for the medicine to treatment. British administration; expenditure by missionsis Malnutrition is rare and has been observed chiefly not included. in artificially fed babies or infants at the weaning Malaria is one of the most important causes of stage.Diet is in general adequate; there is no shortage death in the islands, and together with pneumonia of food, since arable land is plentiful and the popula- and respiratory tuberculosisislargely responsible tion is small. for infant mortality.Anti -mosquito measures in Vila There are no facilities in the New Hebrides for and Luganville are undertaken as part of the routine higher education.Assistant medical practitioners are work of the sanitary squads, and have contributed trained at the Central Medical School in Suva, Fiji, much to reducing the prevalence of malaria in these asare some nurses and dressers.Some student two urban areas; elsewhere, free issues of antimalarial nurses are also sent to the nursing school in Nouméa, drugs are made in certain areas, but no general New Caledonia, but the majority of nurses and control campaign is yet in operation.Other major dressers are trained locally, most of the institutions causes of morbidity are yaws and helminthic infections ; providing courses and in- service training. influenza and bacillary dysentery are endemic, as The town of Vila has a piped water supply, and are amoebiasis and filariasis in certain areas, and there although no purification system has yet been installed, are about 100 known cases of leprosy. an analysis of the water carried out at Nouméa showed By reason of the widely scattered population and an absence of colibacilli.In thevillages,water the large number of islands, there is no central organi- supply generally depends on the collection of rain- zation for maternal and child care.Pre -natal and water.In Vila and some other areas sewage disposal post -natal consultations are given inthe various is mainly by septic tank, and the Condominium dispensaries and out -patientclinics,and various Sanitation Service provides a daily garbage disposal forms of sickness are treated in the course of these service in the Vila urban areas.Elsewhere, disposal consultations.Mothers are also given advice about of waste is of the usual village type, by means of infant feeding and on various hygienic measures. latrines and ditches.
NEW ZEALAND
New Zealand consists of two main islands in the South The country is divided into counties (121), boroughs (143), Pacific Ocean, separated only by a narrow strait, and a number and town districts (16), for local government, and the counties of small islands scattered widely over the ocean. A large part have sub -divisions, perpetuating the old English name of of the main islands are mountainous, the principal range being " ridings ". the Southern Alps, which extend along the whole length of The principal exports are derived from agriculture, with butter, South Island.Some of the mountains of North Island are cheese, and other milk products at the head of the list, followed volcanic. closely by meat and its products.Production is mainly in the In general terms, two -thirds of the total area of 267 985 square hands of private enterprise. kilometres are suitable for agriculture and grazing.About Education is compulsory between the ages of 7 and 15, and for 68 500 square kilometres are still under forest.The climate is the standard course is entirely free.There is a system of moist -temperate marine, with abundant sunshine and at the correspondence courses for children in remote areas. lower levels a small range of temperature. The chief ports of New Zealand for ocean -going ships are The majority of the people are of European descent; in 1958 Wellington and Auckland.Most of the 6000 kilometres of there were 147 800 Maoris (the aboriginal Polynesians) out of a railways are State -owned; mountains and river gorges make population of 2 275 515. construction difficult and costly. 374 FIRST REPORT ON THE WORLD HEALTH SITUATION
Health in the 2 -16 age group should have been offered vacci- nation.Vaccination of special groups and pregnant The health organization is under the control of a women has also been undertaken. Minister, with a professional staff including the Direc- Attention is given to health education. and good tor- General and his Deputy, and divisional officers progress has been made by the issue of films and whose duties cover the whole range of health services. booklets and by specific instruction in such subjects The divisional directors at headquarters work through as the control of hydatid disease.In conjunction and with the district medical officers of health.The with the Department of Agriculture a vigorous health Dominion is divided into 14 districts, each of which is education campaign has been undertaken for this in the charge of a medical officer of health who has purpose.Four health education vans have recently full local responsibility for the health services.The been equipped and sent out to the more remote public health personnel include 80 doctors, 59 dentists, areas. 808 dental nurses, 271 nurses and five pharmacists. In the Division of Child Hygiene in 1957 there The percentage of budget allocated to central health were 21 whole -time and 20 part -time medical officers. administration is 10.84. Great attention is paid to the examination of pre- In 1957, the birth rate was 26.20, the death rate school children, as an educative and preventive mea- was 9.34, and the infant mortality rate was 24.31. sure.In the primary schools, inspection is carried In the hospital services, the ratio of beds per 1000 out by nurses in the first instance and only those sus- population in 1957 was 8.The total number of beds pected of defect are referred to the doctors.The in public institutions was 14 986 and in private hos- work in the post -primary schools was confined mainly pitals 2425.There were also 111 beds for treating togiving BCG vaccination.There are now five the sick in old peoples' homes.In some areas there child health clinics, which deal with child guidance is an acute shortage of beds for long -stay chronic as well as with general physical defects. elderly patients, orthopaedic cases and those suffering The position of environmental sanitation is not yet from acute injuries, for children, for maternity cases, satisfactory.It has hitherto been the practice of and for certain groups needing isolation facilities.On towns or boroughs to discharge crude or inadequately the other hand, there is a surplus of beds for tuber- treated sewage into the sea or a nearby river, but culosis patients, especially in sanatoria.Difficulty is with the growth of population this is giving rise to experienced inobtaining adequate nursingstaff, serious problemsofriverand beachpollution. especially for maternity beds, and admission to some Major sewage works have recently been approved of the larger hospitals has to be regulated according for a considerable number of small towns, and to the staff available.The number of whole -time additions to public water supplies are also being medical officers was 469 in 1957, including junior undertaken. house surgeons.During 1957, 14 378 persons were Since the war, the Department has found it necessary under the care of mental hospitals at one time or to organize its own training scheme for health in- another; the weekly average of occupation was 9847. spectors.This has been done in co- operation with Vaccination against poliomyelitis has progressed Wellington Technical College, and a full -time course very satisfactorily, and by the end of 1958 all children was started in 1949.
NIUE ISLAND
Niue Island is situated in the South Pacific at 169° west and by the Medical Department under the control of the 19° south.It has an area of about 259 square kilometres.It is Chief Medical Officer with, in 1957, a matron, a child an isolated unit, not forming part of any recognized group of islands.The 1956 population was 4634, of whom 45 were welfare sister, a ward sister, one medical and two Europeans.The population seems to be following the usual dentalassistants,and18nurses. A further15 pattern of Polynesian countries, with a steady decline after persons are employed in auxiliary services, including European contact and the introduction of new diseases; this is an assistant health inspector, a laboratory and x -ray followed by a long static period, and then comes an increase, assistant and a dispenser.In January 1958 the staff gradual at first and then accelerating. was increased by two assistant medicalofficers. Health The Niuean assistants are graduates of the Central There are no private medical or dental practitioners Medical School in Fiji, and selected nurses are trained on the island; free medical and dental care are provided in Apia Hospital (Western Samoa).Expenditure WESTERN PACIFIC REGION 375
on health in 1957 amounted to 13.8 per cent. of the people.Filariasis has been reduced to a low level. total expenditure of the island. Tuberculosis is still a problem, but preventive work In 1957 there were 45 deaths, mainly in the chronic through BCG vaccination is applied widely to children, and elderly group; the infant mortality rate improved andisa routine procedure at school age.The (from 30.2 in 1956) to 26.7, and the birth rate rose fact that there are no serious health problems in the to 50.0.This does not imply a considerable increase island is due to increasing co- operation between an in population,as many people migrate to New understanding people and a keen administration. Zealand.There is one hospital to serve the island, Niue is not troubled by housing problems, as every but minor ailments are treated by means of a mobile man is his own builder.All the materials except clinic.Every schoolchild has a complete dental roofing iron and cement are abundant and cheap. examination once a year, and pre -school children A few palm -leaf thatched houses remain.Spraying also receive care at the school clinics. with dieldrin has been valuable in reducing the insect In the latter part of 1956, a campaign against population.Rubbish collections are made weekly in yaws was carried out, covering 75 per cent. of the the main settlement and monthly in the outer villages.
NORTH BORNEO
North Borneo consists of the northern end of the island of The large townships and many of the principal urban areas Borneo in the Malay Archipelago.The territory is largely were almost totally destroyed during the war, so that the housing mountainous and widely forested, and contains some inland problem in the main towns has been acute. A central Town plains and alluvial coastal flats.The narrow plain on the coast and Country Planning Board has been set up to deal with the supports the main agricultural and rubber production of the seven chief towns, and plans have also been drawn up for the territory.The climate is cool for an island on the equator, the smaller townships.Private building has been slow and a average mean temperature ranging from 19° to 31° C.The system of sponsored building loans was begun in 1955. annual rainfall ranges from 150 to 450 centimetres according to the locality, with no clear division between wet and dry seasons. The area is 76 115 square kilometres and the estimated popula- Health tion is nearing 400 000.The distribution in 1956 showed an The Medical Department is under the Director of indigenous population of about 262 000,95 856Chinese, 1794 Europeans and the remainder of varied nationalities. Medical Services, who is responsible for both medical Trade is largely dependent on rubber exports, but by 1954 care and public health.Expenditure on medical and yields were diminishing because of the age of the trees.North health services in 1954 amounted to Str $2 143 384. Borneo is slowly recovering from the effects of the war, and as (US $707 387); this figure represents only the cost of its economy depends on rubber, timber, coco -nuts and copra, the prospects are good.The Government undertook a large -scale running the services and does not include municipal- reconstruction programme in 1954 to encourage rubber planting ityconservancyservices,capitalexpenditure on and other industries.There is a Standing Committee of the new buildings, or grants received under development Legislative Council under the development and welfare schemes. schemes. Rice is the most important food crop.The chief imports are textiles, clothing, machinery and oils. Government medical and health personnel in 1956 In 1954 the Government decided that primary education were as follows: 13 medical officers, one surgeon, should become free, commencing with vernacular education, one dental surgeon, one matron, six nursing sisters, and that it should gradually assume responsibility for all schools. 15staff nurses, 18 trained nurses, 26 probationer Whilst mission and some Chinese schools retain direct respon- nurses, 90 dressers, 37 certified midwives, one dental sibility, a fully representative Board of Education has been set up and is supplemented by a system of local education com- technician and 15 health inspectors.There were also, mittees for each of the 14 school areas.The present educational either in private practice or appointed by missions, system provides for six years of primary education in Malay, 30physicians,four nursingsisters,52dressers, Chinese or English, followed by three, five or six years of and 49 midwives. secondary teaching in English or Chinese. Medical care is provided by two general hospitals In spite of the mixture of races there is no serious problem of cultural relations.The Government's declared policy is to (324 beds) and five cottage hospitals (300 beds); there encourage the enterprise of the Chinese and other immigrant is a mental hospital at Sandakan with an average of communities and to do everything possible for the progress and 120 in- patients; the leprosarium has an average of welfare of the indigenous people.Great emphasis is placed on 45 in- patients. A tuberculosis hospital is being com- teacher training, and all this encourages a rise in the standard of living and an improvement in health.In some areas native pleted at Jesselton.There are two health centres, in reservations have been set up to prevent the indigenous people Jesselton and Sandakan, which provide ante -natal and from being submerged by the immigrants. infant welfare clinics in addition to general services. 376 FIRST REPORT ON THE WORLD HEALTH SITUATION
Thirty dispensaries serve the rural areas, and 12 fo centres throughout the territory, where rehabilitation them have a total of 177 beds for light cases.An services as well as treatment will be available.In the ambulance dispensary serves districts within 30 kilo- control of this disease the Government is assisted by metres of Jesselton, and on the east coast a motor the North Borneo Anti -Tuberculosis Association, launch pays regular visits to the more remote stations. founded in 1953, which is active in health education There is no medical school in North Borneo, the work and spends a large part of its funds on relief nearest being the University of Malaya, to which the and welfare work among tuberculosis patients and Government provides scholarships. There is, however, their families. a training school for nurses, both male and female, Maternal and child health services are provided at under the tuition of a fully qualified sister -tutor, and health centres and dispensaries, and although few 24 male and 15 female student nurses are at present reliable statistics are available, it is evident that infant under training.There is also a scheme for training mortality is declining, particularly in districts well assistant nurses in Jesselton and Sandakan, and tem- served by maternal and child welfare clinics.In porary courses are given for unregistered midwives. one such district, for example, the infant mortality During 1954 and 1955 a health inspector from New rate decreased from 129.4 in 1951 to 84.1 in 1954. Zealand trained nine students, and a laboratory There is some lack of vitamins in the diet that expert from Australia gave training in laboratory could be relieved if more use were made of the techniques. vegetables and fruits which are, or could be, grown. The most serious diseases are malaria, tuberculosis The remedy lies mainly in broader education, par- and intestinal infestations.As in many tropical areas, ticularly of the housewife.For this purpose advice where standards of hygiene and sanitation are rather and diet supplements are offered at the health centres low, gastro -intestinal infections form a high pro- and at the government dispensaries.People who live portion of the diseases, and efforts are being made to in the coastal districts and can get fish are on the reduce this. whole better nourished than those who live in the A pilot scheme for malaria control was begun interior. in 1955 and, if successful, will be extended to cover The rebuilding of the larger centres of population the whole territory. and the provision of public works to improve water Facilities for diagnosis and treatment of tuberculosis supply and drainage has made progress and has are improving; during the period under review, new brought modern sanitation into the towns.Rural x -ray equipment was installed in the two general communities rely on unprotected wells and polluted hospitals, and plans were made for the establishment rivers and streams for their water supply, but there of special wards for tuberculosis patients at various is a rural well improvement scheme.
PACIFIC ISLANDS
The Trust Territory of the Pacific Islands comprises about at about 10 per cent. of the entire budget for the 2000 islands with a total land mass of 1691 square kilometres territory. spread over 7 770 000 square kilometres of ocean.The popula- tion in 1957 was estimated at 67199.There is no urban Efforts are being made to secure the compilation population; the people live in small villages scattered throughout of vital statistics for the islands, and one of the the islands. Navy medical officers investigates each death in the In the report on the Saipan District for the years 1954-56 it is Saipan district. noted that the population is gradually increasing and is now over 7000.The district consists of 12 single islands and one There are eight hospitals in the territory, and a group of three small islands.The total land surface is approxi- ninth is under construction.There are four leprosaria, mately 400 square kilometres, and two -thirds of this is made up 10 dental clinics, and - in the outlying communities - of the two principal islands, Saipan and Tinian. 123 dispensaries.Saipan Hospital functions as a sanatorium, with 40 -70 patients suffering from tuber- Health culosis, and some 30-50 with other diseases.Medical field trips are made periodically to the more remote All public health services are under the Director areas, and health assistance is regularly available to of Public Health and include both clinical care and the population.The combined staff for all these preventive work; the entire staff participates in this services consists of 11 military personnel, one United dual function.The total health costs are estimated States Civil Service nurse, and 71 indigenous staff. WESTERN PACIFIC REGION 377
Micronesian medical and dental students, nurses given.Immunization against tuberculosis with BCG and technicians are given advanced training in schools has begun in the territory. and hospitals outside the territory, in addition to Maternal and child health activities include pre- the continuous in- service training they receive while natal clinics, held once a week, and post -natal clinics, in the public health service of the territory. A held twice a week, at the hospital and the outlying nursing shortage exists, and nursing aides are being dispensaries.Emphasis is being given to the teaching trained in the hospitals. A health centre, which of health and sanitation practices, both in the schools also serves as a practical teaching area for nursing and among adult groups.The nutritional status of students, was recently put into commission and has the people is generally good. been greatly appreciated by the people. A psychiatrist from Guam visits Saipan once a The most prevalentdiseasesaretuberculosis, quarter to examine and treat cases of mental illness. infestation with helminths, gastro -enteritis, dysentery, At the district centres and in some adjacent areas, respiratory infections and skin infections.The leading water is supplied by means of pipelines from depend- causes of death during 1956 were pneumonia, tuber- able and supervised sources.In other areas, fresh culosis and diseases of the heart. water is obtained by rain catchment or from springs, Most babies and children and a large percentage streams and shallow wells.District sanitarians check of the adults have been vaccinated against smallpox, and supervise the water supply, including chlorination and some inoculations against tetanus have been and examination of samples.
PAPUA AND NEW GUINEA
The territory of Papua and New Guinea comprises the eastern been acting as adviser and many Papuans are showing an half of the island of New Guinea, with four groups of adjacent interest in improved design and lay -out. islands.It is wholly within the tropics and is separated from Australia by the Torres Straits.It thus extends north to south from the equator to 11° south, and west to east from 141° Health to 160 °.The total area is 475 350 square kilometres, most of Health services were inaugurated soon after the which is extremely mountainous.There are, however, extensive plains and a number of wide, grass- covered valleys in the main establishment of the two territories.In the early ranges.Many of these are favourable to tropical cultivation days, a curative approach was necessary in order to and the climate is pleasant. gain the confidence of the people, but a gradual In 1956, the population was estimated at 1 739 451, including advance was made towards preventive medicine. 21 166 non -indigenous inhabitants. The primitive though reasonably effective institutions The principal crops are vegetables and fruit.Copra and rubber provide the main exports.Livestock production is on of the past are now being replaced by hospitals and a small scale and is far from satisfying consumption require- clinics of modern standards, in which the newer ments.The general vegetation inland is forest, which restricts techniques of medicine are being employed.Lack to some extent the areas suitable for agriculture.There is a of staff and want of facilities for research delayed certain amount of mining.The principal imports are food, metals and machinery.There is an increasing trade in salt and developments in public health during the years before fish from the coast and foodstuffs from the highlands. the Second World War, but there was substantial Education is free for boys and girls in both the government and gradual progress.Many problems, however, and the mission schools. A law passed in 1954 provided for remain to be overcome -the difficulties of terrain, compulsory education, inspection of schools, and registration and classification of teachers.Correspondence courses are population distribution, multiple languages and social provided by the Department of Education for teachers, both organization have so far prevented cohesive social to extend their own scholastic knowledge and to prepare them and political unity. for examinations.Handicraft work as a part of adult educa- Since the war, the Commonwealth Government has tion is being developed by the Department.During 1954, been speeding up the development of these territories. special courses were given for 19 teachers going to out -stations. In the highlands, people live in villages which are largely The Department of Health was inaugurated in 1945 self -contained communities, and they subsist by growing food and is in the charge of a Director.The territory in their gardens and by hunting.On the coasts there are also has been divided into14 administrativedistricts villages and larger communities.Men come down from the in each of which a District Medical Officer is res- highlands to work, and their employers are required to give them suppressive treatment against malaria. ponsible for health matters. Inland, housing consists almost entirely of primitive huts. There are 15 hospitals of the European type, of which The housing specialist of the South Pacific Commission has 11 are governmental, and 115 hospitals of one kind 378 FIRST REPORT ON THE WORLD HEALTH SITUATION or another are for indigenous patients.Most of the dysentery and tuberculosis.Malaria is also the major government hospitals have separate wards for tuber- sourceofwidespreaddebilityandmorbidity. culosis patients. Extensive antimalaria work is carried on in the terri- At the local level, in addition to hospitals in the tory, and assistance in this connexion is given by main centres, there are 1191 aid posts and health WHO throughfellowships. A MalariaControl centres dispersed throughout the territory,staffed School provides courses of training for indigenous by indigenous orderlies who are capable of giving and non -indigenous personnel. simple treatment; serious cases are transported to the A mass BCG vaccination campaign has been hospitals.Every health centre takes part in infant undertaken, and a very large number of people have and maternal welfare services, and mobile units cater been vaccinated. for the needs of the scattered communities.The Health education of the public is primarily the branch of the Australian Red Cross Society in Port responsibility of the central Department of Health, Moresby has a blood transfusion service.There are particularly the nutrition and infant and maternal also medical stores at Port Moresby, Lae and Rabaul, welfaresections,which areveryactiveinthis each with its own pharmacist under the direction connexion. of a Chief Pharmacist at Headquarters in Port The school medical service is developing gradually Moresby. and a school nurse has been appointed for Port In some respects the demand for medical services Moresby. has outstripped the capacity to provide them.It is Responsibility for the aged and infirm is generally the policy of the Government to use trained indigenous undertaken by the indigenous inhabitants as part of staff wherever possible, and their training is being the collective obligation of the family. carried out not only within the territory but also at Nutritional and dietary surveys have been made the Central Medical School in Suva, Fiji. from time to time in various areas and are still in During the period 1954 -56 the Department of Health progress. had four dentists and there were also eight private Fullyequipped laboratoryserviceshavebeen dentalpractitioners.Thisgivesonlyaskeleton organized in Port Moresby, Lae and Rabaul, with service and great difficulties have been encountered full -time pathologists in charge.There are also a in recruiting additional staff. number of smaller laboratories under the care of There are not at present sufficient data to give trained technicians. accurate birth and death rates.Itis known that Port Moresby has a piped water system, but in infant mortality is high among the indigenous people other towns the water supply is derived mainly from and may be of the order of 250 -300. rain -water storage with supplementary supplies from Broadly speaking, the main health problems are wells during the dry seasons.The total water supplies those of a tropical country, but because of the rural in the towns cater for approximately two per cent. of nature of the life of the people the transmission of the population.Outside the towns, streams and disease is lessened. On the other hand, the difficulties rain -water storage are the principal sources.Sewage of communication increase the problems involved disposal is chiefly by the conservancy system in the in bringing medical services to the people.The towns, with trenching or discharge into the sea. main causesof deatharemalaria,pneumonia, There is one small sewerage scheme in Port Moresby.
REPUBLIC OF THE PHILIPPINES
The Philippines are a group of islands in the South China Sea, Public schools are co- educational and no fees are charged. about 800 kilometres from the south -east of the Continent of Teaching is mainly in English but Spanish is obligatory in all Asia.The islands are mountainous, the ranges running gener- high schools.In addition to the State -supported University of ally in the direction of their axes.In many parts the mountains the Philippines, which had over 9000 students in 1952, there are lie close to the sea and there are narrow and interrupted coastal some 90 accredited private institutions of higher learning. strips, fertile valleys inland, and many forests in the mountain The economy is predominantly agricultural, the chief products areas.The total area is 299 404 square kilometres.There is being rice, coco -nuts, maize, sugar -cane, manila hemp, fruit, a great variety of climate; the prevailing winds are north and tobacco and timber.There is a preponderance of home -made east, and typhoons are not uncommon. goods, but the number of factories is increasing. In 1956 the population was 21 856 857.It was estimated in The main ports of entry to the country are Manila, Cebu, 1948 that 62 per cent. of the population over ten years of age Iloilo, Zamboanga and Davao.There is a good deal of coastal were literate. and river traffic.Highways have been considerably extended WESTERN PACIFIC REGION 379 since the war and now approach 30 000 kilometres. There are special hospitals have a further 5400 beds.In addi- 1200 kilometres of railways, of which the main service is in tion, 217 private general hospitals provide 7036 beds, Luzon. A national airline maintains a network of local stations and there are international connexions with the main cities of and 19 private special hospitals have a bed capacity the world. of 1614.The total number of beds available in all types of hospitals is therefore 18 725.In the ortho- Health paedic units a considerable amount of rehabilitation of the handicapped is being carried out, especially in The national health administration is vested in a relation to poliomyelitis.Under the terms of the Department of Health, headed by a Secretary of rural health law mentioned above, and of its successive Health with the rank of cabinet member. The Office amendments, 1300 rural health units and 262 dental of the Secretary includes an Administrative Division, units are to be established throughout the country; a Division of Tuberculosis, a Division of Health by 1957 a total of 952 senior and 132 junior rural health Education and Information, and a Nursing Division. units had been set up and were already contributing The Department is otherwise composed of a Bureau considerably to the strengthening of the national of Health, a Bureau of Quarantine, and a Bureau of health services.Senior rural health units are assigned Hospitals -each under a Director -and also includes to a municipality or group of municipal districts with the Institute of Nutrition, the public health research a population of not less than 5000; for a municipality laboratories, and all city health departments.At the of 35 000 or more an additional junior rural health provincial level, health matters are administered by unit is assigned. A senior unit is staffed by a physician provincialhealthofficersactingasdirectrepre- -the municipal health officer -as head of the unit, sentatives of the Director of Health and the Secretary a public health nurse, a midwife, a sanitary inspector of Health.Health activities at the local or municipal and a clerk- driver (if the unit is provided with jeep level are under the municipal health officer, who is transport). A junior unit is made up of a physician responsible to the respective provincial health officer. or public health nurse as head of the unit, and a Vital statistics for the years 1954, 1955 and 1956 midwife or sanitary inspector as member of the were as follows: team. 1954 1955 1956 The control of communicable diseases is one of the Birth rate 33.2 34.1 34.7 major functions of the Bureau of Health.Consul- Death rate 10.3 9.9 10.1 Infant mortality rate . . . . 94.2 84.3 83.9 tative and advisory services are provided for the provincial and municipal healthoffices,including There have been important developments in health ad hoc epidemiologicalinvestigations.Systematic legislation during the period under review.In 1954 progress has been made in vaccination and immuniza- a rural health law was passed, whose object was to tion of the general population and the amount of improve the health conditions of the rural inhabitants, research on both acute and chronic preventable who constitute two -thirdsof thepopulation;it diseases is increasing. provided for the establishment of senior and junior The tuberculosis control programme has made note- rural health units in the municipalities and the appoint- worthy progress; a National Chest Centre Clinic for ment of public health dentists in each congressional research and training has been established and put into district. A second law passed in1954 effects a operation; four new static chest clinics and six mobile reorganization of the Division of Tuberculosis and the chest clinics have been set up; 30 BCG teams are in planning of a national programme; among its impor- operation; three additional tuberculosis wards have tant provisions are the construction of a national been established in provincial hospitals; a pilot project tuberculosis centre and a national clinic. A third has been started in Ilocos Norte, and better co- ordina- law relates to nutrition, particularly to the eradication tion has been achieved with the work of the Philippine of beri -beri by means of enrichment of rice; it provides Tuberculosis Society.Furthermore, a rest -settlement for the compulsory admixture of pre -mixed rice in house is under construction. the rice mills throughout the country, regardless of The Bureau of Quarantine is active in the prevention location, in the proportion of one part of pre -mixed of quarantinable diseases, of which no cases were to 199 parts of other types of rice. registered in the Philippines in 1956 or 1957.The There are 80 government hospitals in the Philip- Director of Quarantine is authorized by law to pro- pines,fiveof which providespecializedservices mulgate and enforce, with the approval of the Secretary (for communicable diseases, maternity and paedia- of Health, such rules and regulations as are in his trics, orthopaedic cases, and mental patients); the judgement necessary to prevent the introduction, 75 general hospitals have a total of 4675 beds, and the transmission or spread of quarantinable diseases from 380 FIRST REPORT ON THE WORLD HEALTH SITUATION foreign countries.This refers to plague, cholera and findings on industrial hygiene, and educational activi- smallpox, since no case of yellow fever, typhus or ties.Seminars on industrial hygiene and occupational relapsing fever (also quarantinable diseases) has ever medicine have been held at regular intervals during been registered in the Philippines.Quarantine inspec- the past five years for physicians, dentists and nurses tion of international aircraft and ocean -going vessels employed by industrial concerns. is performed regularly, the latter including all vessels A survey made in 1950 showed that there were some from foreign ports, any vessel with communicable 50 000 mentally sick and mentally defective individuals diseases on board, and vessels from domestic ports in the Philippines, and this does not include the large where quarantinable diseasesprevail.During the penumbra of psycho- neurotic cases.At the present years 1956 and 1957, there was a total quarantine time there is only one hospital for the care of the inspection of 188 233 passengers and crew of 5217 air- mentally ill, and there are relatively few psychiatrists craft,andof 322 219passengersand crewof either in practice or in training, and probably not 6077 vessels. more than a dozen fully- trained psychiatric nurses Maternal and child health work is carried out both and social workers.The mental hospital is seriously through the rural health units and through 508 child overcrowded and has to accommodate at present welfare centres, which are supported partly by the some 4000 patients, which is more than twice its normal Government and partly by voluntary contributions. capacity.It has only limited facilities for therapy; At the national level, these centres are co- ordinated facilities for shock therapy exist, but there are none for by the Section of Puericulture Centres in the Bureau of surgical procedures or specialized diagnosis.Recrea- Hospitals; they provide pre- natal, delivery and post- tional and occupational therapy is given to a limited natal care (including a domiciliary obstetrical service), extent as far as staff is available.In view of the training for auxiliary staff, and mother- and parent - urgent need to train more staff, the hospital is being craft classes.In areas where both rural health units used by all the medical and nursing schools as a and child welfare centres exist, the former undertake training hospital in psychiatry, in spite of its limited public health work other than maternal and child facilities. health, which is the responsibility of the child welfare The main laboratory services are located in Manila centres. but several other towns are developing both research School health services are dealt with by the Division and production. of Medical and Dental Services under the Department Post -graduate training in public health is offered at of Education.The Bureau of Health maintains a the Institute of Hygiene in the Philippines, leading to public dental service which carries out both educational the certificate of master of public health.Physicians, and preventive work in addition to treatment by nurses, dentists, sanitary engineers and health educa- travelling dental units.In private schools the law tors are qualified for admission to this advanced requires the employment of a dentist when the enrol- training course.There are in addition, special training ment exceeds 300, and in the public schools dental courses for midwives, public health nurses and a health is handled on a semi -voluntary basis with number of auxiliaries. financial contributions from the school pupils. Considerable progress has been made in environ- Health education of the public is the responsibility mental sanitation and by 1956 nearly 15 000 water - of the Office of the Secretary of Health; a six -year supply systems had been developed, operated and programme was started in 1954, and assistance is given maintained by the Government, serving one -third of by this Division in all aspects of public health work, the total population.Progress made in treating wells including the distribution of literature, films, posters, and protecting springs has been encouraging.Water and other equipment, as well as the assignment of samples are submitted to the Department by provincial health educators to programmes as required.An health officers, and approximately one -third have been active training programme is in progress, and a number found satisfactory. of health educators have been assigned as members of Outside the city of Manila it is estimated that about rural health unit teams. half the families have some type of sewage- disposal Health care of the chronic sick and the aged is dealt system, but this does not mean that the effluent is with entirely by voluntary agencies. satisfactory in anything like that proportion of cases. Occupational health is the concern of a section of A good deal of attention is being directed to the the Bureau of Health, which undertakes field work, pollution of streams by factory effluents, and corrective laboratory services both for research and for factual measures have been taken. WESTERN PACIFIC REGION 381
PORTUGUESE TIMOR
The Portuguese Province of Timor, which consists of about the total number of deaths in 1954 is given as 6156, half the island of the same name (the other half being Indo- in 1955 as 8425 and in 1956 as 7784. nesian territory), has a total area of 18 909 square kilometres and lies between latitudes 8° 7' and 9° 28' south and longitudes There were no very marked changes in the health 124° 2' and 127° 22' east. situation in Timor during the period under review. The population of Portuguese Timor was estimated in 1956 No quarantinable diseases were notified. at 478 688, with a density of 23.3 per square kilometre. A Permanent Mission for the Survey and Control The province is administered by a local Governor, who has authority over all the State services. of Endemic Diseases is to be formed with the object of investigating the principal diseases so that their Health epidemiology will be better known and appropriate treatment can be applied. The structure of the health services is based on a During the years 1954 -56 a malaria survey was Decree of 1945, under which the health services in carried out, which is to form the basis of a campaign the Portuguese overseas provinces were reorganized. for the control of this disease.Residual insecticide The highest authority in matters of health is the central spraying has been carried out for a number of Health Directorate, which is in charge of three sec- years in the main centres of population, accompanied tions - medical, pharmaceutical, and administrative. by chemotherapy, and the beneficial results of these There is a district health service in Dili the capital, activities are already being felt by the urban population. and six subsidiary district services throughout the Plans are being made to set up mobile units for malaria province. control, which will come into operation when the Curative and preventive medical care is provided Permanent Mission has been established. in Dili by the Central Hospital, a maternity hospital Plans are also being made to organize a tuberculosis with a pre -natal clinic, and a health centre.In the controlservicefor both preventive and curative rest of the province there are three government hos- purposes. pitals and 48 health units with some in- patient ac- Maternal and child health activities have developed commodation.The health units are staffed by male considerably both in the hospitals through nurses and are visited periodically by medical officers district health services, and a programme for further attached to the subsidiary district health services. development is being drawn up. A training course There is also a private hospital at Natubessi owned for auxiliary domiciliary midwives has been established by the Agrícola, Pátria e Trabalho Society.In the and was attended by six students in 1954 and three government health establishments all medical care in 1956.There is also a training course for auxiliary is entirely free of charge to the indigenous inhabitants male nurses, which was attended by 25 students in 1954 and State officials. A programme of hospital cons- and 23 in 1956. truction and further development of health care of the Progress is being made in housing, urban develop- population is being drawn up. ment, and drinking -water supplies, particularly in In 1956, the staff of the health services consisted connexion with the programme of reconstruction of of 11 physicians, 54 nurses and nine midwives. the chief urban centres which were destroyed during It is not possible to establish crude death rates or the war; this programme is being carried out as quickly infant mortality rates; from records available, however, as the economic resources of the province permit.
SARAWAK
Sarawak is in the north -west part of the island of Borneo, in The principal exports are oil, rubber and pepper.In agri- the South China Sea.The country generally is well watered and culture, with the exception of the few rubber estates, small- traversed by many navigable rivers.Towards the interior the holdings predominate and agricultural policy is directed to the land becomes mountainous and the eastern boundary is formed encouragement of the small native farm rather than the large by a broken range rising to peaks of about 3000 metres.The plantation.Rice is the main food crop.Poultry and pigs are climate is healthy and the heat is never extreme.The area of kept widely, and the breeding of goats and cattle is being the country is approximately 122 000 square kilometres. developed.Of the mineral resources, only bauxite and oil are Theestimatedpopulationatmid -1957was640141, at present being worked to any extent. includingabout435 000 indigenousinhabitants, some In many parts of the interior, a village normally consists of 193 000 Chinese (the largest non -indigenous group), and about one " long -house ".Elsewhere similar houses are built raised 2200 Europeans. about two metres from the ground; this provides a good aid to 382 FIRST REPORT ON THE WORLD HEALTH SITUATION
ventilation, but sanitation is usually primitive.In addition to and fully qualified dentists visit other centres from the permanent villages, many tribes have temporary settlements time to time.There is only one fully trained private near the rice- fields, to which they move during the planting season. dentist in Sarawak, but there are quite a number There was a serious shortage of imported foodstuffs imme- of assistants in private practice. diately after the war; supplies were brought in by the military Registration of births and deathsisstillvery administration anddistributedatcontrolledprices.The incomplete, although considerable progress is being situation has now returned to normal, but the export of rice is still prohibited. made in bringing records up to date.The following rates were reported from urban areas for 1957: Health birth rate, 23.9; death rate,6.6.; infant mortality rate, 72; and maternal mortality rate, 5.6. The Central Government is responsible for the There is an extensive maternal and child health organization of nearly all the medical and health work organization in the main centres, which isbeing in the country.The Department of Health is under rapidly expanded by the use of locally trained midwives a chief medical officer, the Director of Medical and in the more isolated districts.No specific school Health Services.The local authorities also have cer- health service has been created, but schoolchildren are tain health services, especially in the larger centres. treated without charge atall government medical. In small places the only health personnel are the institutions.Support for the chronic sick and aged midwives. is provided largely by voluntary organizations, in some Voluntary organizations such as the Social Welfare cases with indirect government subsidy. Council, the Anti -Tuberculosis Association of Sarawak Since 1952 large numbers of rural midwives have and the British Red Cross Society, work in close been trained and have returned to their own districts, liaison with the government medical services. so that the standard of rural midwifery has been very At the present time the health personnel consists considerably raised.The principal centres for the of 24 doctors, four dental officers, 15 matrons and training of midwives are Kuching and Sibu, but a sisters, 226 nurses (male and female), 85 assistant few are also trained in Simanggang, Mini and Brunei. nurses, and 67 midwives and assistant health visitors. Legislation for the licensing of midwives has been There are also 42 sanitarians, 22 laboratory technicians introduced, but at present it is only operative in the and six x -ray technicians. municipal areas of Kuching, Sibu and Mini. There are government hospitals at Kuching, Simang- Hospital returns still show a fair number of patients gang and Sibu, and a government tuberculosis hospital suffering from lack of vitamins and anaemia.There is established at Miri, where there is also a hospital isalso evidence of widespread protein deficiency run by an oil company.The total number of general among the country population.The Medical Depart- beds is 666.There is also a new mental hospital ment is taking active steps to distribute dried skim just outside Kuching, which has 350 beds, with room milk free of charge to pregnant and nursing mothers for expansion to double its present size.In the same and children, and the Department of Agriculture is area there is a tuberculosis sanatorium with 36 beds. increasing the number of pigs and poultry and Considerable extensionsarein progressatSibu encouraging the building of fish -ponds. hospital, where several new wards have already been Overcrowding in the chief towns of Sarawak remains completed and others are under construction.The a serious problem.In Kuching, the first municipal new Simanggang hospital, which will have about housing scheme of 532 units has been completed. 100 beds, was started in June 1958 and building is A low -cost housing scheme of 92 units has also been proceeding rapidly.The Government has a well - completed in Mini.In other towns, progress has equipped dental department at Kuching and Sibu, been made with slum clearance and rebuilding.
SINGAPORE
Singapore Island, which is at the southern extremity of the tion to a water supply by pipeline.In general conformation Malay Peninsula, covers an area of about 362 square kilometres. the island is similar to the mainland. Included within it are the City of Singapore, the naval base, a The population, according to the 1957 census, was 1 474 063, number of military installations, five airports and some small with a density of over 4000 per square kilometre.More than islands. A causeway connects it with the mainland across the 30 races are represented (with Chinese predominating), each Straits of Johore and brings in road and railway traffic in addi- distinguished by its own way of life, its customs and traditions. WESTERN PACIFIC REGION 383
At the end of 1957 there were 668 schools, with a total of dation for chronically sick patients.The Kandang 260 000 pupils.These are divided between government and Kerbau Hospital is the only government institution government -aided schools, and a few private institutions. which deals with the therapeutic aspect of maternity and gynaecology, and it has 316 beds, of which 50 are Health reserved for gynaecological work.This isalso a The City Council administers a very thickly popu- teaching hospital for students from the University lated area of some 900 000 people, and is responsible of Malaya, and it trains midwives for the Certificate for all the environmental and some personal health of the Central Midwives Board. services.The remainder of the territory is under the The estimated birth rate in 1957 was 43, showing jurisdiction of the Rural Board, and the Government a rise since 1931, when it was 36.The general trend Health Division, under the Director of Medical Ser- in the infant mortality rate is a steadily descending vices, is responsible for all health services in this area. one; from 285 in 1944, it has declined to 41 for all The Assistant Director of Medical Services (Health) races in 1957; the Malay rate, however, still remains isadviser and exofficio member of the Rural very high, at 87.The crude death rate, which was 12 Board. in 1951, fell to 7.3 in 1957. The Ministry of Health is responsible for providing Both in the city and in rural Singapore the prin- hospitals and out -patient department services through- cipal infectiousdiseaseis pulmonary tuberculosis. out the territory.The development of an island - The Health Division has been concentrating on wide school medical and dental service,air and education of the public and the prevention of tuber- port health quarantine service and maternity and culosis in schoolchildren.During 1957, 31 796 chil- child health services in the rural areas is at an ad- dren were tested and 26 338 were protected by BCG vanced stage.In addition, a large number of volun- vaccination.Under the Australian Colombo Plan tary bodies play a very important part in the medical assistance, a tuberculosis case -finding programme by care and welfare of the people. free mass radiography was initiated in June 1958, with The Institute of Health, which was donated to a view to determining the nature and extent of the Singapore by the Government of the United King- disease in Singapore and providing a basis for the fu- dom, was opened in May 1958.Ithouses the ture tuberculosis control programme. University's department of social medicine and public Leprosy has been a diminishing disease since 1900, health, a modern maternity and child health centre owing to modern methods of treatment and the run by the City Council, and the government school segregation of complicated cases in hospital.The health service. Trafalgar Home is the institution for the treatment The total expenditure in Singapore on medical of infectious leprosy; it has undergone considerable and health services in 1957 was over M $35.5 million expansion in recent years and has been developed (US $11 716 172). on the open village principle, now housing over There has been a steady increase during the post- 1000 patients. war years in the demand for hospital care, and the With its unique geographical position, large numbers various government hospitals provideatotalof of passengers, ships' crews and air crews pass through 6084 general beds, including 250 beds for infectious Singapore, and the island maintains an effective port diseases, 1000 in the leprosy settlement, 120 ortho- health and quarantine service.There has been no paedic beds, a mental hospital of over 2000 beds, outbreak of epidemic diseases during the last nine and 1147 tuberculosis beds.The general hospital years; malaria has been eradicated.The pandemic is the only one in the territory for the treatment outbreak of influenza reached Singaporeatthe of general medical and surgical conditions.Itis beginning of May 1957; it spread rapidly and had continually overcrowded, and a figure of 1200 given spent itself by the end of May.The number of as the basic bed -strength is still inadequate for the cases in Singapore was estimated to be at least needs of the territory.The most significant increase 150 000. of patients has been in the out -patient department. In October 1958, Singapore experienced a minor The problem of the chronic sick continues to handi- outbreak of poliomyelitis.Voluntary immunization cap the efficient running of thehospital, partly of all children under 10 years of age with Sabin because of the high cost of a general hospital (which vaccine was undertaken, and it was expected that does not permit of long occupation), and partly over 100 000 children would be immunized. because there is no alternative hospital provision There are seven maternity and child health centres for chronic cases. A district hospital is, however, in the city, while in the rural areas there are 19 main under construction which will also provide accommo- child health centres and seven midwifery centres, 384 FIRST REPORT ON THE WORLD HEALTH SITUATION
besides 25 clinic session centres.The rural maternity both children and teachers. and child health staff consists of 10 medical officers, The department of psychological medicine has one public health matron, 11 health sisters and 33 been developing steadily and now offersa very health nurses, in addition to 60 midwives and several comprehensive service to the community.In the health attendants. Woodbridge Hospital the usual standard treatments Facilities are provided for nurses to gain experience are carried out.The hospital gives instruction to in domiciliary midwifery by posting them to one of final -year medical students and to post -graduates the clinics in the rural area.Departmental mid- studying for the Diploma inPublic Health. A wives have been provided with residential accommo- training school for nurses in mental diseases has dation in all the main clinics and some of the out- also been set up and a two -year course is being lyingislands Midwives attendedhalf thetotal organized. confinements in 1957. Almost 90 per cent. of the population is now The school health service provides routine examina- served by a piped water supply, although in certain tion of schoolchildren, treatment of minor ailments parts of the rural area it is unfortunately still necessary and nutritional defects, and reference to specialists to rely on local wells.The entire piped water supply as required.It is also concerned with the control has now been fluoridated, an achievement of con- of tuberculosis and other infectious diseases.Dental siderable importance in preventive dentistry. defects are referred to the school dental service, Building projects are proceeding favourably in the which has a centralclinic adequately staffed by rural area, and large sanitary and modern housing dental officers.There are also three dental travelling estates have appeared in many places.Some of dispensaries for scheduled regular visits to schools. thesedevelopmentsconsistof low -costhousing The tuberculosis control section of the school health projects for workers in the rural area.In all these service carries out a thorough system of BCG vacci- new housing estates and private buildings water -borne nation and x -ray control, including contacts among sewage disposal has been introduced.
TOKELAU ISLANDS
The Tokelau Islands are a group of atolls, three of which The main diseases are yaws and filariasis, but eye (Fakaofo, Nukunono and Atafu) are New Zealand dependencies. and skin troubles are common, the latter being due A census of the New Zealand group taken in 1956 showed a total population of 1875. to local conditions resulting from the limited supply of fresh water.In January 1956 there was a severe, but short, outbreak of poliomyelitis, and special Health services had to be introduced to deal with the emer- gency.In April 1957, almost the entire population The medical services are administered from the contracted measles: the epidemic was mild, and by Health Department of Western Samoa, from which June only a few isolated cases were occurring.In regular visits are made by European medical officers. general, the communications between the Tokelau For the year 1956, the expenditure on health amounted Islands and Samoa are sufficient to ensure reasonable to 18 per cent. of the total budget. control services against the common infections. A medical practitioner is now stationed in each Housing conditionsarefairly good,the most of the three islets, and nurses and dressers are distri- persistent problem being overcrowding.The islanders buted throughout the territory.The entire staff was take pride in their villages, and the appearance of the trained at Apia Hospital (Western Samoa) and is homes and the village paths and grounds is very able to deal with all but the more serious surgical pleasing.As there are no sources of fresh water conditions.Emergencies are dealt with by means of except rain, the people are dependent on methods a radio service.Each islet has an active women's of collection and storage; in recent years the Govern- committee, which does a great deal to improve village ment has eased the situation by the provision of sanitation. tanks. WESTERN PACIFIC REGION 385
TONGA
Tonga, also known as the Tongan or Friendly Islands, is pay a daily fee of three shillings (US $0.35).The located about 480 kilometres east -south -east of Fiji in the Infant Welfare Service is staffed by one New Zealand - Southern Pacific.It has an area of 700 square kilometres, and a population (at the beginning of 1956) of 56 292, comprising trained sister, two staff nurses, and one trainee.The 54 661 Tongans, 286 Europeans, and 1345 others.Geologically Child Welfare Service is gradually assuming respon- the islands are mostly coral, and some of them are of volcanic sibility for the care of pre -school children, although origin. this work benefits from the co- operation of all the The cultivation of grain and rice is being introduced to an health services. increasing extent; previously the population depended almost Schoolchildren are examined regular- wholly on root crops such as yams, taro and sweet potatoes. ly, and BCG and antityphoid immunization pro- The principal industry is copra, which in 1955 returned an grammes are carried out.The majority of the aged active trade balance of £T 525 067 (US $1 176 225). and the chronic sick, except those suffering from chronic infectious disease, are cared for at home, where Health medical services are supplied free by the Govern- ment.Health examinations are obligatory at three - Todaytherearethreegovernmenthospitals: monthly intervalsforall food -handlers in shops Vaiola General Hospital at Nuku'alofa, Tongatapu and stores. (the capital island), which has 95 beds for medical A nutritional survey of government and mission surgical, and infectious cases, including a tuberculosis schools in 1956 showed that there existed a general ward and a maternity ward; Ngu Hospital at Neiafu, protein deficiency ámong the pupils, and that they Vava'u, with a capacity of 60 beds; and Niu'ui suffered commonly from skin lesions, such as impe- General Hospital, at Pangai, Ha'apai, with 20 beds. tigo, scabies and tinea, as well as from respiratory Six rural dispensaries extend theservicesof the diseases. above hospitals to the remote areas. In 1955, short -term fellowships were granted to The health personnel consists of two doctors, one local nurses to attend nursing seminars, and in 1956 acting as the chief medical officer at Vaiola Hospital, similar fellowships were given for refresher courses and the other as the consulting physician at Vava'u; in village hygiene and preventive medicine. 22 assistant medical practitioners; four dispensers; A serious public health problem in Tonga is water one sanitary inspector; two assistant pharmacists; pollution due to the insanitary condition of the wells one government dentist, and 17 staff nurses.There (the sole source of drinking -water in some places are also some 20 assistants assigned todoctors, during the dry season), and to inadequate safeguards sanitary inspectors and laboratory personnel. for sewage disposal and latrines. The population maintains a steady annual increase The authorities are well aware that further improve- of about 3 per cent.The crude birth rate is high ments arestill needed, despite the great progress and steady at around 38 (37.8 in 1956), while the made during this century.Future health plans for death rate shows a tendency to decrease (6.9 in 1956). the Kingdom of Tonga include: a new dispensary The infant mortality rate was about 33.75 in 1956, in Vava'u; a leprosy station to be established in as compared with 58.7 in 1954. Tonga, thus avoiding dependence upon Fiji for this A yaws control campaign is under consideration, service; the organization of a district nursing service; and assistance in conducting it has been requested the expansion of the maternity and surgical facilities from WHO. at the main hospital of Vaiola; the acquisition of Some interesting arrangements have been made x -ray equipment for Niu'ui Hospital to make the for carrying out the health work in this small but antituberculosiscampaign moreeffective;and a well organized island group.Both medical and more efficient organization of the Tongan Public dental care are free to Tongans, with the exception Health Department, with a view tosubsequent of those admitted to the tuberculosis ward, who expansion of its activities. 386 FIRST REPORT ON THE WORLD HEALTH SITUATION
VIET NAM
Viet Nam occupies the eastern part of former French Indo- (2)supervision of pharmacies and laboratories China, with a long coastline on the South China Sea.By a (health,bacteriological and for medical analyses), decree of 1949, the area was divided into three zones -North, Centre and South.After the Geneva Agreement in 1954, the and of the distribution and use of toxic substances northern zone and a part of the central zone north of the or narcotics; 17th parallel were separated off and became North Viet Nam. (3)control of venereal diseases,cancer, tuber- South Viet Nam (south of the 17th parallel) consists of part of the Central Region, the Southern Region and the mountainous area culosis, leprosy, malaria, trachoma and epidemics; of the south (Pays Montagnard du Sud), which is now directly (4)prevention of communicable diseases and social under the Government of the Republic. hygiene; The greater part of Viet Nam is mountainous, but there is a narrow coastal plain and in the south a fertile plain in the (5)education and training of auxiliaryhealth Mekong delta.The combined area is 329 600 square kilo- personnel and para -medical personnel; metres. In 1954, the population of the whole country was estimated at (6)the drawing up and implementation of a 26 million, with a density of 79 per square kilometre.Of these, national plan for improvement of medical and health some 12.5 million lived south of the 17th parallel.The capital, facilities ; Saigon, has a population of over 1.5 million. The majority of the people are of Vietnamese stock, but a (7)liaison with the Vietnamese Red Cross, the number of other racial types are found in the mountainous areas, International Red Cross, the World Health Organiza- particularly in the Pays Montagnard du Sud. tion, and congresses of international medicine. The main occupations are agriculture, fishing and forestry. There is some industrial development in the former Northern A National Board of Health was created in 1951 Region and a tendency in this direction is noticeable in and as a consultative body to deal with all questions around Saigon. concerning improvement of the public health. The economy of the country has suffered severely from the At the effects of war. A ten -year development programme for industry national level the Secretary of State is assisted by a and a three -year plan for agriculture were announced by the Director of Cabinet, a Director -General of Health Government in 1954 and are now being carried out.The and Hospitals, and a Director of General Administra- main products are rice and rubber, but forestry and fishing are tion, who is in charge of the central staff. growing in importance. General public education is given in some 3500 primary, Up to 1956 no statistical service had been established 230 secondary and 68 technical schools.The University of in the Ministry of Health, but a central statistical Saigon is controlled and operated by the Government.About bureau deals with demographic data; the organiza- three- quarters of its teaching staff are Vietnamese and the tion of more -developed services in the Ministry of remainder are foreign. Health is envisaged. The principal ports are Saigon and Tourane.In 1956, there were about 14 500 kilometres of roads, of which 3000 -3500 kilo- Hospitals for general medicine and surgery, as well metres were asphalted.The railway system has now been as specialized units, have been established in the repaired, and runs from north to south through the whole cities and the provincial capitals.In Saigon, the length of the country, with a number of branch lines.Civil Hôpital populaire has 375 beds and acts as a teaching aviation has been managed, since 1953, by a joint company in which the State controls more than 51 per cent. of the shares. unit of the University. A new children's hospital There is an international airport near Saigon and four or with 260 beds has recently been opened and is extreme- five other airfields for internal traffic. ly active.In 1956 some 60 beds were already in service, and an out -patient department was dealing with 300 children a day.The Cho -Ray Hospital Health (also a University teaching hospital) has 870 beds for In 1956, when the Constitution of the Republic general and special care.Infectious diseases are dealt came into force, the Ministry of Health was placed with at the Choquan Hospital, which has 320 beds. under the authority of a Secretary of State, who is The tuberculosis hospital (formerly the President Thinh directly responsible to the President.The functions Hospital) has 400 beds.In Saigon there are also of the Secretary of State are: two large maternity homes and several other medical establishments. (1)preparation and implementation of legislation The main institutions in the provinces include a on health establishments and organizations, the prac- mental hospital (1100 beds) at Bien -Hoa and a large tice of the medical and para- medical professions, number of general and specialized units distributed pharmacy and dentistry ; throughout the country. WESTERN PACIFIC REGION 387
The Ministry has set up three dental health centres year of studies in physics, chemistry and biology. in Saigon.There is a shortage of dentists, and a Altogether more than 900 students are enrolled in number of private practitioners give part -time help the Faculties of Medicine and Pharmacy.There in the hospitals and dental clinics. are schools for nurses and midwives at Saigon and at Until 1954, progress in maternal and child health Hué. work was slow, owing to lack of staff and financial The cities and most of the district capitals have resources.There are not enough centres for pre- piped water supplies, and some have relatively satis- natal care, but training of rural midwives has begun factory sewage -disposal systems.The construction under the direction of the provincial medical officers. and installation of septic tanks is also being developed In 1954, the Department of Health drew up a large - in these areas. scale plan for the extension of maternal and child The Institut Pasteur in Saigon has prepared various health services in Viet Nam, and considerable assist- vaccines, including BCG, and has a public health ance has been received from WHO and UNICEF laboratory service, which is active in the control of in its implementation. water pollution. A special unit has been set up to deal with insect In the large cities, straw huts are gradually dis- vectorcontrol,and modern methods arebeing appearing and are being replaced by concrete houses. introduced in the control of malaria, tuberculosis In recent years the Government has paid special and leprosy.There is a laboratory service at the attention to the shortage of housing, and is building national school for medical biology. low- priced apartments in the cities and provincial The Medical Faculty of the University of Saigon capitals, which it makes available to the population offers a six -year medical course after a pre -medical on a hire -purchase basis.
WESTERN SAMOA
The territory of Western Samoa lies between 13° and 15° south On the educational side, there is as yet no provision for a and 171° and 173° west.It comprises two large islands, Savai'i compulsory system.As more schools are built and teachers and Upolu, the small islands of Manono and Apolima, and are trained it should be possible to extend the compulsory several islets lying off the coasts, and has a total land area of system district by district, and even at present wherever there about 2929 square kilometres.The formation is mainly of are government village schools there is free primary education volcanic rocks, with coral reefs surrounding the coasts.Rugged for boys and girls.Secondary education is available for children mountain ranges form the core of both main islands, with selectedby competitiveexaminations. During thepast heights reaching over 1100 metres.The climate is tropical with eight years the Government has carried out an extensive school a wet summer and a drier winter, and no great range of tem- building programme with assistance from the respective districts perature.The population at the 1956 census was approximately and villages, and modern well- constructed schools are now 97 000, with 18 000 living in Apia, the capital, and the remainder numerous. on the coasts, in some 400 villages.After the New Zealand Maoris, the Samoans are the largest Polynesian race, and they speak a Polynesian dialect.Most of them live within a social Health system based on the alga, or extended family group, headed by a matai.The matai is elected by the common consent of the A non -official member of the Executive Council, family members, and he assumes responsibility for directing the as the member for health, is responsible for the affairs use of the family lands; he also represents his family group in of the Department of Health.He is assisted by a village and district councils. Economically, Western Samoa is primarily an agricultural standing committee of theLegislative Assembly. country and, with the fishing industry, is largely self -sufficient. The administration of health servicesisexercised Copra, cocoa, and bananas are produced for export. by the Director of Health.There is one central The structure of Samoan society has changed little in the past 250 -bed hospital at Apia and 14 district hospitals at century.The members of an alga need not live under the same convenient points in both islands, providing a total roof or in the same village, but they will assemble as of right when anything occurs to affect their interests.As organized of 200 beds.In recent years the Director of Health groups women have an important part to play in Samoan has also held the position of medical superintendent society and in public health and welfare; but individually their of Apia Hospital, but in 1958 a separate super- status changes with that of their men. Women may hold any intendent was appointed.The Director is assisted public office and exercise all public functions on equal terms with men, and there is no differentiation between the sexes in by five qualified medical practitioners and 43 Samoan the right to work.Girls and boys have equal opportunities to medical practitioners,thelatterbeing men who compete for scholarships. have graduated from the Medical School in Fiji. 388 FIRST REPORT ON THE WORLD HEALTH SITUATION
They are experienced within the limits of their training Leprosy stands at a low level; only 16 new cases were and do practically all the day -to -day medical work reported during 1957. outside the capital. The principal pre -natal clinic is at the Apia Hospital In 1957 there was a total of 234 Samoan nurses, and provides a service which is growing rapidly. of whom 94 have completed fulllocal training. Child health clinics, especially for the younger groups, The staff is headed by a matron, an assistant matron, are a regular feature of the work of district nurses a sister -tutor and nine nursing sisters, all of whom and the major part of the preventive programme. are nurses registered in New Zealand. There are no reliable figures about the extent to which No accurate figures for the principal causes of the mothers have skilled attendance by doctor or mortality have yet been worked out.Work is now midwife duringchild- birth,although a reporting proceeding to analyse statistics about the causes of system has now been set up. infant deaths.The number of deaths reported in 1957 Housing presents no difficulties in Samoa.The was 659, of which 164 were infants.During the same great majority of islanders still live in their traditional year, 3931 live births were reported. well -built thatched " fales ".There are also quite Owing to its isolation, Samoa is free from plague, a number of part Europeans and some full Samoans malaria, cholera and smallpox.Filariasis and yaws in and around the capital who live in European or areendemic, buttheirprevalenceisdecreasing. semi -European type houses. INDEX OF COUNTRIES
INDEX OF COUNTRIES
Aden (Colony and Protectorate), 319 El Salvador, 181 Italy, 271 Afghanistan, 215 Ethiopia, 326 Jamaica, 187 Alaska, 155 Japan, 362 American Samoa, 347 Federal Republic of Germany, 255Jordan, Hashemite Kingdom of, 333 American Virgin Islands, 156 Federation of Malaya, 368 Angola, 101 Federation of Nigeria, 128 Kenya (Colony and Protectorate), Antigua, 189 Federation of Rhodesia and Nyasa- 120 Argentina, 157 land, 133 Korea, Republic of, 364 Ascension, 136 Fiji, 356 Laos, 366 Australia, 347 Finland, 247 Lebanon, 334 Austria, 233 France, 251 Leeward Islands, 189 French Departments in America, 182 Liberia, 122 Bahama Islands, 159 French Equatorial Africa, 111 Libya, United Kingdom of, 335 Barbados, 159 French Guiana, 182 Luxembourg, 275 Basutoland, 102 French Polynesia, 357 Bechuanaland Protectorate, 104 French Somaliland, 327 Macao, 367 Belgian Congo, 105 French West Africa, 113 Madagascar, 124 Belgium, 235 Malaya, Federation of, 368 Bermuda, 161 Gambia (Colony and Protectorate),Martinique, 182 Bolivia, 162 115 Mauritius, 126 Borneo, North, 375 Germany, Federal Republic of, 255 Mexico, 191 Brazil, 164 Ghana, 118 Monaco, 276 British Guiana, 166 Gibraltar, 258 Morocco, 277 British Honduras, 167 Gilbert and Ellice Islands, 358 Mozambique, 127 British Solomon Islands Protector-Great Britain and Northern Ireland, ate, 350 United Kingtom of, 307 Nepal, 225 British Somaliland Protectorate, 107 Greece, 259 Netherlands, 278 British Virgin Islands, 190 Grenada, 210 Netherlands Antilles, 193 Brunei, 351 Guadeloupe, 182 Netherlands New Guinea, 370 Bulgaria, 238 Guam, 359 New Caledonia, 371 Burma, 216 Guatemala, 183 New Hebrides, 372 Guiana, British, 166 New Zealand, 373 Cambodia, 352 Guiana, French, 182 Nicaragua, 194 Canada, 168 Guinea, Portuguese, 131 Nigeria, Federation of, 128 Cape Verde, 109 Niue Island, 374 Ceylon, 218 Haiti, 184 North Borneo, 375 Chile, 173 Hashemite Kingdom of Jordan, 333 Norway, 282 China, Republic of, 353 Hawaii, 186 Nyasaland, Federation of Rhodesia Colombia, 174 Honduras, 187 and, 133 Comoro Archipelago, 110 Honduras, British, 167 Cook Islands, 355 Hong Kong, 360 Pacific Islands, 376 Costa Rica, 176 Hungary, 261 Panama, 195 Cuba, 177 Panama Canal Zone, 196 Cyprus, 320 Iceland, 265 Pakistan, 337 Czechoslovakia, 240 India, 220 Papua and New Guinea, 377 India, Portuguese, 226 Paraguay, 197 Denmark, 242 Indonesia, 222 Peru, 198 Dominica, 209 Iran, 328 Philippines, Republic of, 378 Dominican Republic, 178 Iraq, 329 Poland, 285 Ecuador, 180 Ireland, 267 Polynesia, French, 357 Egypt, 323 Israel, 331 Portugal, 288 - 391 - 392 FIRST REPORT ON THE WORLD HEALTH SITUATION
Portuguese Guinea, 131 Singapore, 382 Turkey, 300 Portuguese India, 226 Solomon Islands, British, 350 Portuguese Timor, 381 Somaliland, British, 107 Uganda, 145 Puerto Rico, 200 Somaliland, French, 327 Union of South Africa, 148 South Africa, Union of, 148 Union of Soviet Socialist Republics, Réunion, 132 Spain, 294 304 Rhodesia and Nyasaland, Federa-Sudan, 340 United Kingdom of Great Britain tion of, 133 Surinam, 201 and Northern Ireland, 307 Romania, 290 Swaziland, 141 United Kingdom of Libya, 335 Ruanda -Urundi, 135 Sweden, 296 United States of America, 203 Switzerland, 298 Uruguay, 206 St Christopher- Nevis -Anguilla, 190 Syria, 342 Venezuela, 207 St Helena, 136 Viet Nam, 386 St Lucia, 210 Tanganyika, 142 Virgin Islands, American, 156 St Vincent, 211 Thailand, 227 Virgin Islands, British, 190 Samoa, American, 347 Timor, Portuguese, 381 Western Samoa, 387 Samoa, Western, 387 Togo, Autonomous Republic of, 144 Windward Islands, 209 São Tomé and Principe, 137 Tokelau Islands, 384 Sarawak, 381 Tonga, 385 Yemen, 344 Seychelles, 138 Trinidad and Tobago, 202 Yugoslavia, 313 Saudi Arabia, 339 Tristan da Cunha, 137 Sierra Leone, 139 Tunisia, 343 Zanzibar, 150